title: 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.
authors.affiliation: Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Shailja V
authors.initials: SV
authors.lastname: Parikh
authors.forename: Ellen C
authors.initials: EC
authors.lastname: Keeley
mesh_terms: D054058:Acute Coronary Syndrome / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects*; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D003661:Decision Support Techniques; D004359:Drug Therapy, Combination; D019317:Evidence-Based Medicine; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D018570:Risk Assessment; D012307:Risk Factors; D013927:Thrombosis / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors
references.citation: JAMA. 2000 Aug 16;284(7):835-42
references.pmid: 10938172
references.citation: JAMA. 2004 Jun 9;291(22):2727-33
references.pmid: 15187054
references.citation: J Cardiovasc Med (Hagerstown). 2009 Aug;10(8):616-23
references.pmid: 19561526
references.citation: N Engl J Med. 1995 Sep 21;333(12):764-9
references.pmid: 7643883
references.citation: N Engl J Med. 2001 Aug 16;345(7):494-502
references.pmid: 11519503
references.citation: N Engl J Med. 2006 Apr 6;354(14):1464-76
references.pmid: 16537663
references.citation: Ann Pharmacother. 2009 Jun;43(6):1064-83
references.pmid: 19458109
references.citation: N Engl J Med. 1996 Sep 12;335(11):775-82
references.pmid: 8778585
references.citation: J Am Coll Cardiol. 2008 Jan 15;51(2):210-47
references.pmid: 18191746
references.citation: Lancet. 1989 Jun 3;1(8649):1215-20
references.pmid: 2566778
references.citation: J Am Coll Cardiol. 2009 Jun 2;53(22):2019-27
references.pmid: 19477350
references.citation: Am Heart J. 2008 Aug;156(2):209-15
references.pmid: 18657648
references.citation: J Clin Invest. 2001 Jun;107(12):1591-8
references.pmid: 11413167
references.citation: Lancet. 2008 Aug 16;372(9638):537-46
references.pmid: 18707985
references.citation: J Invasive Cardiol. 2008 Feb;20(2):53-8
references.pmid: 18252967
references.citation: Lancet. 2009 Feb 28;373(9665):723-31
references.pmid: 19249633
references.citation: Circulation. 1995 Aug 1;92(3):657-71
references.pmid: 7634481
references.citation: J Am Coll Cardiol. 2008 Sep 2;52(10):807-14
references.pmid: 18755342
references.citation: Thromb Res. 2008;123 Suppl 1:S58-61
references.pmid: 18809206
references.citation: Lancet. 2003 Jan 4;361(9351):13-20
references.pmid: 12517460
references.citation: Am J Cardiol. 2003 Oct 15;92(8):930-5
references.pmid: 14556868
references.citation: J Am Coll Cardiol. 2009 May 5;53(18):1668-73
references.pmid: 19406342
references.citation: Circulation. 1997 Sep 2;96(5):1445-53
references.pmid: 9315530
references.citation: Lancet. 1999 Feb 6;353(9151):429-38
references.pmid: 9989712
references.citation: J Invasive Cardiol. 2006 Nov;18(11):521-6
references.pmid: 17090813
references.citation: Circulation. 1999 Oct 12;100(15):1593-601
references.pmid: 10517729
references.citation: JAMA. 2008 Apr 16;299(15):1788-99
references.pmid: 18375998
references.citation: Circulation. 2001 Jul 31;104(5):539-43
references.pmid: 11479250
references.citation: J Invasive Cardiol. 2005 Jan;17(1):34-8
references.pmid: 15640538
references.citation: Eur Heart J. 2004 Oct;25(19):1688-94
references.pmid: 15451146
references.citation: Br J Haematol. 2002 Jan;116(1):178-86
references.pmid: 11841415
references.citation: Haemostasis. 2000;30 Suppl 3:27-43
references.pmid: 11182626
references.citation: Ann Intern Med. 2006 May 2;144(9):673-84
references.pmid: 16670137
references.citation: Circulation. 2003 Jun 17;107(23):2908-13
references.pmid: 12796140
references.citation: J Am Coll Cardiol. 2000 Mar 15;35(4):915-21
references.pmid: 10732888
references.citation: J Am Coll Cardiol. 2006 Jun 20;47(12):2364-73
references.pmid: 16781360
references.citation: J Am Coll Cardiol. 2006 Oct 3;48(7):1339-45
references.pmid: 17010792
references.citation: Circulation. 2005 Apr 26;111(16):2099-106
references.pmid: 15750189
references.citation: JAMA. 2004 Jul 7;292(1):45-54
references.pmid: 15238590
references.citation: Eur Heart J. 2007 Jul;28(13):1598-660
references.pmid: 17569677
references.citation: Circulation. 2001 Feb 6;103(5):658-63
references.pmid: 11156876
references.citation: N Engl J Med. 2008 Aug 14;359(7):688-96
references.pmid: 18703471
references.citation: JAMA. 2003 Sep 24;290(12):1593-9
references.pmid: 14506118
references.citation: Catheter Cardiovasc Interv. 2009 Feb 1;73(2):214-21
references.pmid: 19156882
references.citation: N Engl J Med. 2008 May 22;358(21):2218-30
references.pmid: 18499566
references.citation: Circulation. 1999 Oct 12;100(15):1602-8
references.pmid: 10517730
references.citation: N Engl J Med. 2001 Jun 21;344(25):1895-903
references.pmid: 11419426
references.citation: Lancet. 2002 Jan 19;359(9302):189-98
references.pmid: 11812552
references.citation: N Engl J Med. 1992 Jul 16;327(3):141-5
references.pmid: 1608405
references.citation: Lancet. 1997 Feb 15;349(9050):474-5
references.pmid: 9040584
references.citation: Circulation. 2000 Jun 6;101(22):2557-67
references.pmid: 10840005
references.citation: N Engl J Med. 1997 Jun 12;336(24):1689-96
references.pmid: 9182212
references.citation: Am Heart J. 2002 May;143(5):847-53
references.pmid: 12040347
references.citation: J Am Coll Cardiol. 2009 Mar 10;53(10):837-45
references.pmid: 19264239
references.citation: N Engl J Med. 1995 May 18;332(20):1330-5
references.pmid: 7715641
references.citation: Circulation. 2009 Jun 9;119(22):2877-85
references.pmid: 19470889
references.citation: Circulation. 2006 Dec 12;114(24):2636-43
references.pmid: 17145988
references.citation: Am Heart J. 2006 Nov;152(5):876-81
references.pmid: 17070148
references.citation: Am Heart J. 2009 Jan;157(1):60.e1-9
references.pmid: 19081397
references.citation: J Am Coll Cardiol. 2001 Mar 15;37(4):1001-7
references.pmid: 11263599
references.citation: Eur Heart J. 2006 Jun;27(12):1401-7
references.pmid: 16682384
references.citation: N Engl J Med. 2006 Nov 23;355(21):2203-16
references.pmid: 17124018
references.citation: Ann Intern Med. 1998 Apr 1;128(7):541-4
references.pmid: 9518398
references.citation: N Engl J Med. 2007 Nov 15;357(20):2001-15
references.pmid: 17982182
references.citation: J Am Coll Cardiol. 2009 May 26;53(21):1965-72
references.pmid: 19460609
references.citation: Circulation. 2007 Aug 14;116(7):e148-304
references.pmid: 17679616
references.citation: Circulation. 2000 Feb 15;101(6):590-3
references.pmid: 10673248
references.citation: Circulation. 2009 Jan 27;119(3):e21-181
references.pmid: 19075105
references.citation: Lancet. 1998 Jul 11;352(9122):87-92
references.pmid: 9672272
references.citation: JAMA. 2004 Jul 7;292(1):89-96
references.pmid: 15238596
references.citation: Am J Cardiol. 2007 Nov 1;100(9):1376-82
references.pmid: 17950793
references.citation: JAMA. 1996 Sep 11;276(10):811-5
references.pmid: 8769591
references.citation: BMJ. 2002 Jan 12;324(7329):71-86
references.pmid: 11786451
references.citation: Circulation. 2002 Nov 12;106(20):2550-4
references.pmid: 12427650
references.citation: J Am Coll Cardiol. 1991 Dec;18(7):1587-93
references.pmid: 1960301
references.citation: J Am Coll Cardiol. 2005 Sep 20;46(6):937-54
references.pmid: 16168274
references.citation: JACC Cardiovasc Interv. 2008 Dec;1(6):639-48
references.pmid: 19463378
references.citation: JAMA. 2006 Apr 5;295(13):1531-8
references.pmid: 16533938
references.citation: Cardiovasc Revasc Med. 2009 Apr-Jun;10(2):88-93
references.pmid: 19327670
references.citation: JAMA. 2002 Nov 20;288(19):2411-20
references.pmid: 12435254
references.citation: N Engl J Med. 2009 May 21;360(21):2237-40
references.pmid: 19458369
references.citation: Lancet. 2009 Jul 4;374(9683):29-38
references.pmid: 19539361
references.citation: N Engl J Med. 2001 Jun 21;344(25):1888-94
references.pmid: 11419425
references.citation: Lancet. 2000 Dec 16;356(9247):2037-44
references.pmid: 11145489
references.citation: Circulation. 2009 Apr 14;119(14):1933-40
references.pmid: 19332467
references.citation: J Am Coll Cardiol. 2008 Jan 15;51(2):172-209
references.pmid: 18191745
references.citation: J Am Coll Cardiol. 2000 Nov 1;36(5):1507-13
references.pmid: 11079650
references.citation: Transfus Med Rev. 2007 Jan;21(1):37-48
references.pmid: 17174219
references.citation: Circulation. 2004 Feb 24;109(7):874-80
references.pmid: 14757697
references.citation: J Am Coll Cardiol. 2009 Mar 24;53(12):1021-30
references.pmid: 19298914
references.citation: Circulation. 1999 Oct 12;100(15):1667-72
references.pmid: 10517740
references.citation: N Engl J Med. 1983 Aug 18;309(7):396-403
references.pmid: 6135989
references.citation: Chest. 2009 Jun;135(6):1651-1664
references.pmid: 19497901
references.citation: Am J Cardiol. 2003 Apr 1;91(7):803-6
references.pmid: 12667564
references.citation: N Engl J Med. 1985 Nov 28;313(22):1369-75
references.pmid: 3903504
references.citation: N Engl J Med. 1997 Aug 14;337(7):447-52
references.pmid: 9250846
references.citation: Vasc Health Risk Manag. 2007;3(2):221-8
references.pmid: 17580732
references.citation: N Engl J Med. 2009 May 21;360(21):2176-90
references.pmid: 19332455
references.citation: Lancet. 2000 Jun 3;355(9219):1936-42
references.pmid: 10859038
references.citation: Circulation. 2007 Dec 18;116(25):2923-32
references.pmid: 18056526
references.citation: J Am Coll Cardiol. 2008 May 6;51(18):1734-41
references.pmid: 18452778
references.citation: Lancet. 1997 May 17;349(9063):1422-8
references.pmid: 9164315
references.citation: J Invasive Cardiol. 2005 Feb;17(2):85-91
references.pmid: 15687531
references.citation: Circulation. 2000 Aug 8;102(6):624-9
references.pmid: 10931801
references.citation: Lancet. 2002 Sep 7;360(9335):743-51
references.pmid: 12241831
references.citation: Circulation. 2001 Jun 19;103(24):2994-3018
references.pmid: 11413093
references.citation: Lancet. 2001 Aug 18;358(9281):527-33
references.pmid: 11520521
references.citation: N Engl J Med. 1988 Oct 27;319(17):1105-11
references.pmid: 3050522
references.citation: Lancet. 1999 Aug 28;354(9180):708-15
references.pmid: 10475181
references.citation: N Engl J Med. 1994 Apr 7;330(14):956-61
references.pmid: 8121459
references.citation: JAMA. 2003 Feb 19;289(7):853-63
references.pmid: 12588269
references.citation: Lancet. 2008 Apr 19;371(9621):1353-63
references.pmid: 18377975
references.citation: Am J Cardiol. 1993 Aug 15;72(5):450-4
references.pmid: 8394644
references.citation: Curr Opin Hematol. 2009 Sep;16(5):347-56
references.pmid: 19550318
references.citation: Am J Cardiol. 2009 May 15;103(10):1396-402
references.pmid: 19427435
references.citation: Circulation. 2009 Apr 14;119(14):1873-82
references.pmid: 19332461
references.citation: Circulation. 1998 Aug 25;98(8):734-41
references.pmid: 9727542
references.citation: Blood. 2008 May 15;111(10):4871-9
references.pmid: 18309033
references.citation: Eur Heart J. 2004 May;25(10):837-46
references.pmid: 15140531