Pretreatment with antiplatelet drugs in invasively managed patients with coronary artery disease in the contemporary era: review of the evidence and practice guidelines.

Abstract

Antiplatelet therapy is the mainstay of pharmacological management in patients with coronary artery disease (CAD) manifestations, particularly those with an acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI).1 In these settings, platelet inhibition with aspirin and a P2Y12 receptor inhibitor is associated with ischemic benefit, although this may occur at the expenses of an increased risk of bleeding.2–4 Clopidogrel is the most studied P2Y12 receptor and still represents the most used across the globe. However, a major conundrum in clinical practice, which has been amplified during the recent years with the development of novel antiplatelet therapies, both oral (prasugrel and ticagrelor) and intravenous (cangrelor), is whether patients undergoing an invasive evaluation should be pretreated with a P2Y12 receptor inhibitor.5 The introduction of novel antiplatelet therapies has also led to question the role of pretreatment with glycoprotein IIb/IIIa receptor inhibitors (GPI).6 Although the need for adequate platelet inhibition is emphasized among invasively managed patients with CAD, the evidence supporting pretreatment, particularly with P2Y12 inhibitors, is somewhat scarce. Indeed, changes in practice patterns in the current era of ACS management, which is typically characterized by shorter timeframes from clinical presentation to the cath-laboratory, have fueled the debate on the benefits of pretreatment. On one side, proponents of pretreatment call into question the need for safeguarding the patient from ischemic events in the early vulnerable period before and immediately after PCI.7 On the other side, challengers of pretreatment raise concerns over the putative unnecessary excess of platelet inhibition and related bleeding risk when patients do not undergo PCI (ie, when medical management or coronary artery bypass grafting [CABG] is needed).8 Overall, in view of the conflicting data and the newly available studies exploring the effect of pretreatment with antiplatelet …