Risk Stratification after an Acute Coronary Syndrome: Significance of Antithrombotic Therapy.

Victoria A Brazhnik,Elena D Kosmacheva,Olga I Boeva,Larisa O Minushkina,Dmitry A Zateyshchikov,Marina A Chichkova,Niyaz R Khasanov

doi:10.3390/jcm10081572

Victoria A Brazhnik, Elena D Kosmacheva + Show 5 more

Open Access

https://doi.org/10.3390/jcm10081572

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Abstract

The impact of the de-escalation strategy of antiplatelet therapy (APT) on the life expectancy after acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI) requires an assessment in real clinical practice. Into the Russian multicentral observational trial (ORACLE II ClinicalTrials.gov number, NCT04068909), 1803 patients with ACS and PCI indications were enrolled. During 12 months of follow-up, 228 all-cause deaths have occurred. The analysis of death predictors was carried out by the classification tree method. Age, an option of antithrombotic therapy, a history of chronic heart failure, and uric acid level had the greatest prognostic value. The death prediction model’s sensitivity was 82.1% in the training cohort and 79.2% in the test cohort. During the observation period, ticagrelor was replaced with clopidogrel (APT de-escalation) in 357 patients. The groups of patients with different antiplatelet therapy options were adjusted for clinical parameters by the pseudorandomization method. The de-escalation group had the lowerest all-cause death rate. The incidence of bleeding and recurrent nonfatal coronary events in the study groups did not differ significantly. Thus, the APT regimen’s advantage of changing from the maximum in the first weeks after ACS to moderate at follow-up has been confirmed. There is an obvious need to study the possibilities of individualizing antiplatelet therapy in patients after acute coronary syndromes.

Highlights

The management of patients with the acute coronary syndrome (ACS) involves longterm dual antiplatelet therapy (APT), including acetylsalicylic acid (ASA) and a P2Y12 inhibitor
The 2018 European Society of Cardiology guidelines on coronary revascularization include a provision that a de-escalation strategy under platelet aggregation control may be considered after percutaneous coronary interventions (PCI) [3]
We considered patients’ clinical characteristics, laboratory testing data, echocardiography parameters, patient status at hospital discharge, antithrombotic and hypolipidemic therapy—189 predictors in total

Summary

Introduction

The management of patients with the acute coronary syndrome (ACS) involves longterm dual antiplatelet therapy (APT), including acetylsalicylic acid (ASA) and a P2Y12 inhibitor. In real clinical practice, only some of patients takes these drugs They are often replaced by clopidogrel (de-escalation of APT) due to therapy’s side effects, the risk of bleeding, and financial reasons. The 2018 European Society of Cardiology guidelines on coronary revascularization include a provision that a de-escalation strategy under platelet aggregation control may be considered after percutaneous coronary interventions (PCI) [3]. This recommendation is based on the results of the TROPICAL-ACS

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