Update on oral antithrombotic therapy for secondary prevention following non-ST segment elevation myocardial infarction

Abstract

Patients with non-ST segment elevation myocardial infarction (NSTEMI) are at high risk for atherothrombotic recurrences. Dual antiplatelet therapy (DAPT) with aspirin and the P2Y12 receptor inhibitor clopidogrel significantly reduces the ischemic events in NSTEMI patients and has represented the mainstay of treatment for over a decade. However, a considerable number of patients continue to experience thrombotic complications, which may be in part due to inadequate platelet inhibition induced by this treatment regimen. This underscores the need for more potent antithrombotic treatment regimens for the long-term prevention of atherothrombotic events in NSTEMI patients. These include novel generation P2Y12 receptor blockers, such as prasugrel and ticagrelor, or adjunctive antiplatelet or anticoagulant therapies, such as vorapaxar [a protease-activated receptors (PAR)-1 receptor inhibitor] or rivaroxaban (a factor Xa inhibitor), respectively. Since ischemic events accrue over time in NSTEMI patients, prolonging intensified antiplatelet therapy beyond 1 year has also been investigated. However, although intensified and prolonged antithrombotic treatment regimens reduce ischemic events, this occurs at the expense of an increased risk of bleeding complications. This article encompasses the current state of the art on antithrombotic therapies for the secondary prevention of atherothrombotic events in patients with NSTEMI.