title: Antiplatelet Therapy Considerations in Ischemic Cardiogenic Shock: Implications of Metabolic Bioactivation.
abstract: Dual antiplatelet therapy with aspirin and a P2Y12 receptor antagonist remains a mainstay in the prevention of ischemic events following coronary stent placement. Significant controversy exists regarding the optimal management of high platelet reactivity despite antiplatelet therapy; however this finding has been consistently associated with poor clinical outcomes including greater risk of stent thrombosis and myocardial infarction. Variability in antiplatelet effects of clopidogrel and prasugrel has been linked to genetic polymorphisms and potential drug-drug interactions. Both of these factors have significant influence on the cytochrome P-450 enzyme system activity of the liver responsible for their biotransformation to the active form of both drugs. Very little has been publicized regarding differences in antiplatelet effects which may be associated with conditions in which the functional capacity of the liver may be temporarily compromised. Patients who present with cardiogenic shock due to acute coronary syndromes have evidence of multiorgan dysfunction including liver dysfunction that may affect the activity of these drugs. This review aims to explore existing evidence and propose additional considerations to the selection of antiplatelet therapy in patients with cardiogenic shock who receive catheter-based revascularization and stent placement.
authors: Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA phillip.weeks@memorialhermann.org.
authors: Phillip A
authors: PA
authors: Weeks
authors: Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA.
authors: Adam
authors: A
authors: Sieg
authors: Center for Advanced Heart Failure, University of Texas Health Science Center, Houston, TX, USA.
authors: Christina
authors: C
authors: Paruthi
authors: Center for Advanced Heart Failure, University of Texas Health Science Center, Houston, TX, USA.
authors: Indranee
authors: I
authors: Rajapreyar
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications; D001241:Aspirin / Q000008:administration & dosage / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D006801:Humans; D009203:Myocardial Infarction / Q000517:prevention & control; D017202:Myocardial Ischemia / Q000150:complications; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000627:therapeutic use; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage / Q000627:therapeutic use; D012770:Shock, Cardiogenic / Q000209:etiology / Q000628:therapy*; D015607:Stents
chemical_list: D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D001241:Aspirin
keywords: P2Y12 receptor antagonist; cardiogenic shock; clopidogrel; prasugrel; ticagrelor