Key result
Adding a non-vitamin K antagonist oral anticoagulant to dual antiplatelet therapy reduces the risk of ischemic events in patients with acute coronary syndrome, albeit at an increased risk of bleeding.
Why the study?
Patients with ACS receiving standard dual antiplatelet therapy have an approximate 10% residual risk for further ischemic events, prompting interest in dual pathway strategies targeting coagulation and platelets.
Does the addition of non-vitamin K antagonist oral anticoagulants to antiplatelet therapy improve ischemic outcomes without unacceptable bleeding risk in patients with acute coronary syndrome?
Does the addition of non-vitamin K antagonist oral anticoagulants to antiplatelet therapy improve ischemic outcomes without unacceptable bleeding risk in patients with acute coronary syndrome?
This review highlights the evolving landscape of secondary prevention in ACS, emphasizing the shift towards dual pathway inhibition (NOAC plus single antiplatelet) to balance ischemic protection and bleeding risk.
Supports dual-pathway regimens in ACS to curb ischemic recurrence; extends prior RCT data while requiring individualized bleeding risk assessment.
Patients with acute coronary syndrome (ACS) require long-term antithrombotic intervention to reduce the risk of further ischemic events; dual antiplatelet therapy with a P2Y 12 inhibitor and acetylsalicylic acid (ASA) is the current standard of care. However, pivotal clinical trials report that patients receiving this treatment have a residual risk of approximately 10% for further ischemic events. The development of non-vitamin K antagonist oral anticoagulants (NOACs) has renewed interest in a ‘dual pathway’ strategy, targeting both the coagulation cascade and platelet component of thrombus formation. In the phase III ATLAS ACS 2 TIMI 51 trial, a ‘triple therapy’ approach (NOAC plus dual antiplatelet therapy) showed reduced ischemic events with rivaroxaban 2.5 mg twice daily, albeit at an increased risk of bleeding. Two studies have investigated the role of NOACs in combination with a P2Y 12 inhibitor, with or without ASA, in reducing bleeding risk in patients with atrial fibrillation undergoing percutaneous coronary intervention; two further studies are underway. Although these trials will help to inform optimal treatment protocols for secondary prevention of ACS, an individualized approach to treatment will be needed, taking account of the high frequency of co-morbid conditions found in this patient population.
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George et al. (2019) conducted a review in Acute Coronary Syndrome. Non-vitamin K antagonist oral anticoagulants (NOACs) vs. Standard dual antiplatelet therapy was evaluated. Adding a non-vitamin K antagonist oral anticoagulant to dual antiplatelet therapy reduces the risk of ischemic events in patients with acute coronary syndrome, albeit at an increased risk of bleeding.
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