Selecting the optimal antithrombotic regimen for patients with acute coronary syndromes undergoing percutaneous coronary intervention

Abstract

The wide variety of anticoagulant and antiplatelet agents available for clinical use has made choosing the optimal antithrombotic regimen for patients with acute coronary syndromes undergoing percutaneous coronary intervention a complex task. While there is no single best regimen, from a risk-benefit ratio standpoint, particular regimens may be considered optimal for different patients. We review the mechanisms of action for the commonly prescribed antithrombotic medications, summarize pertinent data from randomized trials on their use in acute coronary syndromes, and provide an algorithm (incorporating data from these trials as well as risk assessment instruments) that will help guide the decision-making process.

Keywords: anticoagulant; antiplatelet; percutaneous coronary intervention.

Figure 1

The TIMI, PURSUIT, and GRACE risk scores. Abbreviations: CAD, coronary artery disease; CCS, Canadian Cardiovascular Society; CHF, congestive heart failure; MI, myocardial infarction; PCI, percutaneous coronary intervention.

Figure 2

Algorithm for selecting the optimal antithrombotic regimen incorporating cardiac risk, bleeding risk, and clopidogrel pretreatment. In this algorithm it is assumed that all patients have received aspirin. *If bivalirudin is used, a loading dose of clopidogrel should be given as soon as possible in the cardiac catheterization laboratory to decrease the risk of subacute stent thrombosis.