In the first-line treatment of acute coronary syndrome (ACS), ticagrelor and prasugrel have been shown to be effective, according to PD Jan Steffel, MD, Zurich.
Acute coronary syndrome (ACS) includes unstable angina pectoris, non-ST-segment-elevation myocardial infarction (NSTEMI), ST-segment-elevation myocardial infarction (STEMI), and sudden cardiac death. PD Jan Steffel, MD, senior physician in cardiology/rhythmology at the University Hospital Zurich, presented the case study of a 78-year-old male patient with type 2 diabetes mellitus diagnosed five years ago. Two years earlier, he had a transient ischemic attack (TIA) and has been on acetylsalicylic acid (“ASA”) treatment ever since. He suffers from arterial hypertension, which is well controlled. One day he wakes up with very severe chest pain. Diagnosis revealed occlusion of the RIVA (“ramus interventricularis anterior”), and a drug-eluting stent was placed. “The question now is how do you treat the patient? Aspirin® and clopidogrel, aspirin® and prasugrel, or aspirin® and ticagrelor?” says PD Steffel.
For example, in a 2007 study, prasugrel therapy showed a significant reduction in the number of ischemic events, including stent thrombosis, in direct comparison with clopidogrel, but an increased risk of major bleeding, especially in patients after cerebrovascular insult (CVI) or TIA. [3].
Ticagrelor significantly reduces fatal myocardial infarctions, strokes, and overall deaths due to vascular causes compared with clopidogrel. There is no significant increase in the total number of major bleeding events compared with clopidogrel [4].
“Ticagrelor and prasugrel are overall superior to clopidogrel and thus first-line therapy. However, prasugrel is contraindicated in status post TIA or CVI, besides: caveat if age >75 yrs and/or weight <60 kg. Ticagrelor carries the risk of bradycardia and dyspnea as well as drug interactions. Overall, however, good data exist for high-risk populations. Clopidogrel is now only an alternative drug if the two new drugs cannot or must not be used,” said PD Steffel. In individual cases, the decision may be difficult: The above patient is already over 75 and has had a TIA, so the use of prasugrel is contraindicated, although it carries less risk of stent thrombosis than clopidogrel.
Source: “Anticoagulation in atrial fibrillation and ACS – the red thread for everyday practice”, Symposium at Medidays, September 2-6, 2013, Zurich.
Literature:
- Connolly SJ, et al: Apixaban in Patients with Atrial Fibrillation. N Engl J Med 2011; 364: 806-817.
- Connolly SJ, et al: Stroke. The Long-Term Multicenter Observational Study of Dabigatran Treatment in Patients With Atrial Fibrillation (RELY-ABLE) Study. Circulation 2013; 128: 237-243.
- Wiviott SD, et al: Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007 Nov 15; 357(20): 2001-15. epub 2007 Nov 4.
- Wallentin L, et al: Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009; 361: 1045-1057 September 10, 2009DOI: 10. 1056/NEJMoa0904327.
CARDIOVASC 2013; 12(5): 29
Congress Special 2014; (6)1: 22-23
