The role of the interventional cardiologist in selecting antiplatelet agents in acute coronary syndromes: a 10-question strategy

Abstract

Antiplatelet agents play a major role in the management of patients with acute coronary syndromes (ACS). In recent years, the most important development has been the advent of new inhibitors of adenosine 5'-diphosphate (ADP) P2Y12 receptor inhibitors, namely prasugrel and ticagrelor. The arrival of these new drugs on the market, with their specific indications and combinations with aspirin, glycoprotein IIb/IIIa inhibitors, and anticoagulants, has rendered the therapeutic arena more complex. Achieving the best combination of all these drugs for each patient requires sound knowledge of the indications of each molecule according to the clinical situation, as well as evaluation of the ischaemic and haemorrhagic risks. In practical terms, the interventional cardiologist holds the key to therapeutic decisions, based on the anatomical information obtained in the cathlab. He/she should be able to recommend an appropriate antiplatelet treatment strategy even before the patient arrives in the cathlab, or alternatively, adapt or modify treatment according to the possibilities for revascularization, and advise on long-term therapy. In this report, we describe, in ten questions, the key elements that the interventional cardiologists should be ready to answer before choosing the appropriate antiplatelet regimen, based on recent guidelines, and covering the whole spectrum of management from pre-hospital, to the cathlab, and after invasive procedures.

Keywords: Acute coronary syndrome; GP IIb/IIIa inhibitors; P2Y12 receptor inhibitors; angioplasty; antiplatelet.

Figure 1.

Ten useful questions for the interventional cardiologist to guide the choice of antiplatelet treatment in acute coronary syndromes: at first medical contact (top), in the cathererization laboratory (middle), and during hospitalization and at discharge (bottom) Red, questions before choosing appropriate antiplatelet treatment; green, possible treatment options; yellow, particular clinical situations. ACS, acute coronary syndrome; CABG, coronary artery bypass graft; DAPT, dual antiplatelet therapy; ICCU, intensive coronary care unit; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; PCI, percutaneous coronary intervention; Rx, treatment; STEMI, ST-segment elevation myocardial infarction.