title: Beyond aspirin and clopidogrel: is there a need for additional antiplatelet therapy in ACS?
abstract: Dual antiplatelet therapy with aspirin and clopidogrel is a well-established standard of care for patients with acute coronary syndromes. Whether there are other drug strategies or therapies that will achieve fewer ischemic events, and at the same time be associated with fewer bleeding complications, is a question recurrently asked. Finding the appropriate pharmacologic calibration of antiplatelet potency and applying such a pharmacodynamic effect to all patients has only been partially successful. The shadow of this one-size-fits-all dilemma is now being recast with the arrival of newer antiplatelet agents, which are attempting to decouple antithrombotic potency from bleeding liability. Novel antiplatelet agents that act faster and have more consistent pharmacokinetics and higher potency are steadily emerging. Additionally, newer agents that target unique sites, such as the thrombin receptor on platelets, are being studied in large-scale clinical trials. Each of these new agents has the potential to extend net clinical benefits beyond those provided by aspirin and clopidogrel.
authors: Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY 40536-0200, USA.
authors: Lawrence
authors: L
authors: Rajan
authors: David J
authors: DJ
authors: Moliterno
references: N Engl J Med. 2001 Aug 16;345(7):494-502
references: 11519503
references: Cardiovasc Drug Rev. 2007 Winter;25(4):357-74
references: 18078435
references: Lancet. 1990 Oct 6;336(8719):827-30
references: 1976875
references: Circulation. 2009 Jun 9;119(22):2877-85
references: 19470889
references: N Engl J Med. 2007 Nov 15;357(20):2001-15
references: 17982182
references: N Engl J Med. 1983 Aug 18;309(7):396-403
references: 6135989
references: Eur Heart J. 2009 Jul;30(14):1753-63
references: 19435740
references: Circulation. 2007 Dec 18;116(25):2923-32
references: 18056526
references: Circulation. 2005 Nov 8;112(19):2946-50
references: 16260639
references: J Am Coll Cardiol. 2006 Sep 5;48(5):931-8
references: 16949482
references: J Am Coll Cardiol. 2011 Jan 18;57(3):280-9
references: 21232664
references: N Engl J Med. 2004 Jan 15;350(3):232-8
references: 14724302
references: Am Heart J. 2009 Sep;158(3):335-341.e3
references: 19699854
references: J Am Coll Cardiol. 2010 Dec 14;56(25):2126-38
references: 21144974
references: Arterioscler Thromb Vasc Biol. 2009 Apr;29(4):449-57
references: 19023091
references: N Engl J Med. 2009 Sep 10;361(11):1045-57
references: 19717846
references: Circulation. 2010 Jan 5;121(1):71-9
references: 20026770
references: N Engl J Med. 2010 Nov 11;363(20):1909-17
references: 20925534
references: Am J Cardiol. 2006 Nov 20;98(10A):18N-24N
references: 17097413
references: Am J Cardiovasc Drugs. 2005;5(6):399-408
references: 16259528
references: Am Heart J. 2009 Apr;157(4):733-9
references: 19332203
references: Circulation. 2009 Jan 20;119(2):237-42
references: 19118249
references: Am J Cardiol. 2007 Oct 15;100(8):1199-206
references: 17920357
references: N Engl J Med. 2009 Jan 22;360(4):354-62
references: 19106084
references: N Engl J Med. 2009 Dec 10;361(24):2330-41
references: 19915222
references: N Engl J Med. 2010 Sep 2;363(10):930-42
references: 20818903
references: Am J Cardiol. 2008 Apr 15;101(8):1088-93
references: 18394438
references: J Am Coll Cardiol. 2009 Dec 1;54(23):2205-41
references: 19942100
references: J Am Coll Cardiol. 2007 Aug 14;50(7):e1-e157
references: 17692738
references: JACC Cardiovasc Interv. 2010 Jun;3(6):571-83
references: 20630450
references: Circulation. 2009 Dec 22;120(25):2577-85
references: 19923168
references: Lancet. 2010 Jan 23;375(9711):283-93
references: 20079528
references: Lancet. 2009 Mar 14;373(9667):919-28
references: 19286091
references: JAMA. 2006 Apr 5;295(13):1531-8
references: 16533938
references: JAMA. 2009 Mar 4;301(9):937-44
references: 19258584
references: Am J Cardiol. 2009 Feb 2;103(3 Suppl):40A-51A
references: 19166712
references: J Thromb Haemost. 2010 Oct;8(10):2326-8
references: 20695984
references: Circulation. 2006 Sep 5;114(10):1070-7
references: 16952995
references: J Am Coll Cardiol. 2008 Jan 15;51(2):172-209
references: 18191745
references: JAMA. 2010 Oct 27;304(16):1821-30
references: 20978260
references: Am J Cardiol. 2002 Dec 15;90(12):1314-9
references: 12480040
references: Am Heart J. 2009 Dec;158(6):998-1004.e1
references: 19958867
references: Lancet. 2008 Apr 19;371(9621):1353-63
references: 18377975
references: Am Heart J. 2010 Jul;160(1):65-72
references: 20598974
references: Eur Heart J. 2006 Mar;27(6):647-54
references: 16364973
references: JAMA. 2011 Mar 16;305(11):1097-105
references: 21406646
references: Am Heart J. 2009 Sep;158(3):327-334.e4
references: 19699853
references: J Am Coll Cardiol. 2008 Apr 8;51(14):1404-11
references: 18387444
references: Am Heart J. 2010 Feb;159(2):284-291.e1
references: 20152228