Adjunctive Antiplatelet / Antithrombotic therapy in percutaneous coronary intervention.
Antiplatelet and antithrombotic treatment is successful in minimising acute and subacute stent thrombosis as well as reducing recurrent cardiac events and mortality in PCI. In this review we explore the evidence for different treatment strategies.Aspirin and clopidogrel together with heparin at the time of the procedure are now well established. Glycoprotein (GP) IIb/IIIa blockers have been shown to reduce events in high risk patients. However, their routine use has been questioned in recent studies.Clopidogrel 600 mg given at least 2 hours preprocedure negates the need for additional routine GP IIb/IIIa blockade in elective, even diabetic patients. Bivalirudin is equivalent to the routine use of GP IIb/IIIa blockade in both elective and ACS patients. Replacing routine GP IIb/IIIa blockade in these patients would be significantly cost saving, reduce bleeding complications and facilitate rapid discharge policies. However, these studies do not have the patient selection to advocate the wholesale replacement of GP IIb/IIIa blockade since high risk patients were excluded. Furthermore, with the advent of drug eluting stents, progressively more complex lesions are being treated that are underrepresented in these trials. Therefore, there still remains a rational for continuing to use GP IIb/IIIa blockade in high risk subsets of both elective and ACS patients. These subsets are yet to be defined. In the setting of primary PCI clear benefits have been shown for the use of adjunctive abciximab, with the greatest benefits seen for upfront treatment. Future studies will test combinations of GP IIb/IIIa blockade and thrombolytic treatment in these patients.
Eichhöfer
Jonas
J
Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, United Kingdom.
Fraser
Douglas
D
Fath-Ordoubadi
Farzin
F