Beware of Novel Antiplatelet Therapy in ACS Patients with Previous Stroke
Dual antiplatelet therapy with aspirin and the platelet P2Y12 receptor antagonist clopidogrel has become the cornerstone of the treatment of patients undergoing coronary stenting, and of those with acute coronary syndromes with or without stent implantation1. Consequently, many patients in the cardiology practice in 2012 are on dual antiplatelet therapy mainly aspirin and clopidogrel. The only important side-effect of dual antiplatelet therapy is increased bleeding in comparison to aspirin alone. This has been established in the large trials with clopidogrel in acute coronary syndromes2,3 and thereafter4, as well as in atrial fibrillation5. Especially in the latter dual antiplatelet therapy has shown to be as hazardous as oral anticoagulation6. The novel platelet P2Y12 receptor antagonists prasugrel and ticagrelor are more effective than clopidogrel in patients, but show more non-CABG related TIMI major bleeding than clopidogrel7,8. In the latter trial it became clear that patients with a previous stroke had significantly more bleeding with prasugrel, especially intracranial bleeding, than those without a history of stroke. Triple antiplatelet therapy with aspirin, clopidogrel and the oral platelet thrombin receptor antagonist vorapaxar was in 2 megatrials with patients with acute coronary syndromes9 and thereafter10 also more associated with this dreadful complication compared to aspirin and clopidogrel alone. The former study had to be stopped prematurely by the data monitoring committee because of this and in the latter the same had to be done for the patients with a previous stroke or TIA. (SELECT FULL TEXT TO CONTINUE)
- Received April 27, 2012.
- Accepted May 1, 2012.
- Copyright © 2012, American Heart Association, Inc. All rights reserved. Unauthorized use prohibited