title: When is the Best Time for the Second Antiplatelet Agent in Non-St Elevation Acute Coronary Syndrome?
abstract: Dual antiplatelet therapy is a well-established treatment in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), with class I of recommendation (level of evidence A) in current national and international guidelines. Nonetheless, these guidelines are not precise or consensual regarding the best time to start the second antiplatelet agent. The evidences are conflicting, and after more than a decade using clopidogrel in this scenario, benefits from the routine pretreatment, i.e. without knowing the coronary anatomy, with dual antiplatelet therapy remain uncertain. The recommendation for the upfront treatment with clopidogrel in NSTE-ACS is based on the reduction of non-fatal events in studies that used the conservative strategy with eventual invasive stratification, after many days of the acute event. This approach is different from the current management of these patients, considering the established benefits from the early invasive strategy, especially in moderate to high-risk patients. The only randomized study to date that specifically tested the pretreatment in NSTE-ACS in the context of early invasive strategy, used prasugrel, and it did not show any benefit in reducing ischemic events with pretreatment. On the contrary, its administration increased the risk of bleeding events. This study has brought the pretreatment again into discussion, and led to changes in recent guidelines of the American and European cardiology societies. In this paper, the authors review the main evidence of the pretreatment with dual antiplatelet therapy in NSTE-ACS.
authors.affiliation: Hospital TotalCor, São Paulo, SP, Brazil.
authors.forename: Pedro Gabriel Melo
authors.initials: PG
authors.lastname: de Barros e Silva
authors.affiliation: Hospital TotalCor, São Paulo, SP, Brazil.
authors.forename: Henrique Barbosa
authors.initials: HB
authors.lastname: Ribeiro
authors.affiliation: Hospital TotalCor, São Paulo, SP, Brazil.
authors.forename: Antônio Claudio do Amaral
authors.initials: AC
authors.lastname: Baruzzi
authors.affiliation: Hospital TotalCor, São Paulo, SP, Brazil.
authors.forename: Expedito Eustáquio Ribeiro
authors.initials: EE
authors.lastname: da Silva
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy*; D002986:Clinical Trials as Topic; D000077144:Clopidogrel; D006801:Humans; D015201:Meta-Analysis as Topic; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D011292:Premedication / Q000379:methods*; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D013997:Time Factors
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine