De-escalação de inibidores dos receptores P2Y12 após intervenção coronária percutânea / P2Y12 inhibitor de-escalation after percutaneous coronary interventions

Em pacientes que apresentam síndromes coronárias agudas e são tratados com intervenção coronária percutânea, a prescrição do esquema antiplaquetário duplo, composto de ácido acetilsalicílico e um inibidor dos receptores P2Y12, é mandatória, contribuindo para a redução de eventos cardíacos maiores. No entanto, ao mesmo tempo em que previne eventos isquêmicos, essa associação pode precipitar complicações hemorrágicas maiores, o que é mais comumente observado quando são prescritos os medicamentos mais potentes, como o prasugrel ou o ticagrelor. Essas constatações levaram à procura de alternativas terapêuticas capazes de manter a proteção contra eventos isquêmicos e, ao mesmo tempo, prevenir a ocorrência de hemorragias. Uma das estratégias que está em estudo é a de-escalação dos inibidores P2Y12, que consiste no uso dos medicamentos mais potentes numa fase precoce após o procedimento, com substituição deles pelo clopidogrel, após um período de, em geral, 30 dias de evolução; outra possibilidade seria a simples redução da dose do fármaco de maior potência, algo que, até o momento, só pode ser cogitado com o prasugrel. A de-escalação pode ser feita de forma guiada, utilizando testes de mensuração objetiva da agregação plaquetária ou exames para avaliar o perfil genético dos pacientes, ou não guiada, na qual o cardiologista simplesmente faz a substituição ou redução da dose ao fim do período estipulado, sem o auxílio de exames complementares. A literatura contempla ensaios clínicos com essas duas opções de estratégia, os quais são discutidos nesta revisão. Até o momento, nenhuma diretriz médica recomenda de forma explícita o uso regular dessa alternativa terapêutica.

In patients who have acute coronary syndromes and are treated with percutaneous coronary intervention, the prescription of a dual antiplatelet regimen, consisting of acetylsalicylic acid and a P2Y12 receptor inhibitor, is mandatory, contributing to the reduction of major cardiac events. However, while preventing ischemic events, this association may precipitate major bleeding complications, which is more commonly seen when more potent drugs, such as prasugrel or ticagrelor, are prescribed. These findings led to the search for therapeutic alternatives that could maintain the protection against ischemic events and, at the same time, prevent the occurrence of hemorrhages. One of the strategies being studied is de-escalation of P2Y12 inhibitors, which consists of the use of more potent drugs in an early phase after the procedure, replacing them with clopidogrel, after a period of, in general, 30 days of clinical course. Another possibility would be to simply reduce the dose of the most potent drug, which so far can only be considered with prasugrel. De-escalation can be done in a guided way, using objective measuring tests of platelet aggregation or exams to assess the genetic profile of patients, or unguided, in which the cardiologist simply replaces or reduces the dose at the end of the stipulated period, with no ancillary tests. The literature includes clinical trials with these two strategy options, which are discussed in this review. So far, no medical guideline explicitly recommends the regular use of this therapeutic alternative.

The clinical profile of patients with intracerebral hemorrhage after receiving acute coronary syndrome regimen in a tertiary hospital: A case series

@#Coronary heart disease, which includes acute coronary syndromes (ACS) is a major cause of death and morbidity. Treatment for this condition includes dual anti-platelet treatment combined with an anti-coagulant and an anti-dyslipidemic. Bleeding complications may occur and one fatal adverse event is intracerebral hemorrhage (ICH). ACS cases in a tertiary hospital for the years 2014-2018 showed that there were 7 patients who presented with symptomatic ICH after treatment administration that accounts for 0.01% of a total of 1,097 patients. These patients were over the age of 50, but with no sex predilection. Common comorbidities were hypertension and malignancy. All patients presented with acute onset neurologic deficits within 1-4 days after administration of ACS regimen, with ICH scores of 3-4 signifying a high mortality rate of 72-90%. 6 out 7 patients had significant volume of ICH with mass effects, and 1 with subarachnoid hemorrhage. This lead to poor outcome in all patients with 6 out of 7 mortalities and 1 left with substantial disability. It was found that given the total number of patients administered with the said treatment, there is a low incidence of ICH.

Dual antiplatelet therapy for mild stroke and transient ischemic attack / 国际脑血管病杂志

Patients with mild stroke and transient ischemic attack (TIA) have a high risk of early recurrence or deterioration. Antiplatelet therapy has been recognized to reduce the risk of ischemic vascular events. All guidelines recommend antiplatelet therapy for patients with ischemic stroke. Dual antiplatelet therapy (DAPT) refers to the application of two drugs with different mechanisms to block platelet aggregation and prevent thrombosis. There are many combinations of DAPT, and its safety and effectiveness are still uncertain. This article reviews the efficacy and safety of DAPT in patients with mild stroke and TIA.

Different durations of dual anti-platelet therapy after percutaneous coronary intervention with drug-eluting stents in patients with coronary disease: A systematic review / 中国药学杂志

OBJECTIVE: To evaluate the benefits and risks of different durations of dual anti-platelet therapy after percutaneous coronary intervention with drug-eluting stent in patients with coronary disease. METHODS: PubMed, Embase, Cochrane Library, CBM, CNKI, VIP, Wanfang Data, Clinical Trials and ICTRP were searched for randomized controlled trials(RCTs) comparing different DAPT durations after PCI with DES in patients with coronary disease. Risk of bias was assessed with the tool recommended by Cochrane Collaboration. Network Meta-analysis was performed with WinBUGS 1.4.3 and ST ATA 12.0. RESULTS: A total of 3 230 articles were found and 10 RCTs including 31 643 patients were systematically reviewed. Network Meta-analysis showed there was no significantly difference among the 6 different durations in the rates of stent thrombosis, myocardial infarction, all-cause mortality and major bleeding, except that the durations of 6 months [OR 10.56, 95% CI(1.62, 9.17)] and 12 months [OR 4.05, 95% CI(1.01, 11.46)] were different with 30 months in the rate of stent thrombosis. Ranking of cumulative probabilities showed that 30 months and 36 months of DAPT had the lowest risk of stent thrombosis and myocardial infarction, meanwhile duration of 3 months and 6 months had the lowest risk of all-cause mortality and major bleeding. CONCLUSION: Clinicians should assess the risks of stent thrombosis and bleeding according to patient's individual condition and determine the optimal duration of DAPT. It is considered feasible to appropriately extend the duration of DAPT in patients at lower bleeding risk.

Triple anti-platelet therapy protecting acute coronary syndrome patients from complication within 30 days after PCI / 中华急诊医学杂志

Objective To investigate the efficacy and safety of triple anti-platelet therapy (low-dose tirofiban plus aspirin and clopidogrel) comparing to dual anti-platelet therapy (aspirin and clopidogrel) in preventing stent thrombosis (ST) and major adverse cardiac events (MACE) within 30 days after implantation of drug-eluting stent (DES) in ACS patients.Methods A total of 2904 ACS patients treated with DES from March 2004 to November 2010 were enrolled for retrospective study.Of them,1145 patients were treated with dual anti-platelet therapy (DAT) and 1759 patients with triple anti-platelet therapy (TAT).The incidences of ST,MACE (cardiac death,urgent target vessel revasculanization and myocardial infarction) and side effects occurred within 30 days after PCI were compared between two groups by Fisher' s exact test.Results (1)Although there were significant differences in age,the degree of coronary stenosis,the number of smokers,diabetes,hyperlipidemia and coronary diffuse lesion between two groups,but these differences did not impact on the end point events showed by Cox analysis.The rest of the general condition of patients between two groups was no difference.(2) The incidence of ST as primary end point was lower in TAT group than that in DAT group (0.11％ vs.1.05％,P =0.0036),reducing the relative risk by 89.52％.In addition,the incidence of MACT as secondary end point was also lower in TAT group than that in DAT group (0.17％ vs.1.48％,P =0.0005),reducing the relative risk by 88.51％.Among the total,the incidences of cardiac death and urgent target vessel re-vascularization in TAT group were lower than those in DAT group with significant differences.However,there was no difference in the incidence of myocardial infarction between two groups.(3) Both two groups had no severe hemorrhage complication,the incidence of mild hemorrhage was similar in two groups (0.45％ vs.0.35％,P =0.6720).Nesides,the incidence of acute thrombocytopenia between two groups was also similar (0.45％ vs.0.09％,P =0.083).Conclusions The patients with ACS in the TAT group have significant lower incidence of ST and MACE than those in the DAT group within 30 days after PCI.While the risk of bleeding and the incidence of acute thrombocytopenia do not increase.