The Role of New Antiplatelet Agents in Percutaneous Coronary Intervention

While the current armamentarium of antithrombotic agents used in the setting of percutaneous coronary intervention (PCI) has led to decreased mortality, re-infarction and recurrent ischaemia rates, there are also increasing rates of major bleeding events with the use of more potent antithrombotic agents. Major bleeding associated with PCI leads to significantly increased mortality. Additionally, adequate rates of antiplatelet activity are not reached in large proportions of patients receiving clopidogrel due to interactions with its hepatic metabolism. As a result, current research has focused on creating antiplatelet agents that bypass hepatic metabolism, such as prasugrel and ticagrelor, as well as on decreasing major bleeding risks in patients undergoing PCI. Large trials such as ACUITY and HORIZONS have demonstrated that the direct thrombin inhibitor bivalirudin is able to adequately anticoagulate patients undergoing urgent PCI while also significantly decreasing adverse bleeding events. Additionally, novel reversible anticoagulants and factor Xa inhibitors are being examined as agents that may reduce bleeding risk in this patient population.