Antiplatelet treatment after PCI

Editor-in-Chief Antiplatelet treatment is standard after coronary intervention. In this issue of the journal, we focus on antiplatelet treatment after coronary interventions. Randomized controlled trials (RCTs) have demonstrated the superiority of a strategy of patent foramen ovale (PFO) percutaneous closure associated with antiplatelet therapy over a strategy of antithrombotic therapy only for secondary prevention of cryptogenic stroke in patients with a diagnosis of PFO.1–4 These RCTs used various duration of dual antiplatelet therapy (DAPT) ranging from 3 days in the REDUCE trial to 6 months in the DEFENSE PFO trial.1–4 Dr Montalescot and co-workers aimed at assessing outcomes following PFO closure according to the antiplatelet strategy at discharge. They used a cohort included consecutive patients from 7 centers in France and Canada undergoing PFO closure and discharged without anticoagulation. The authors concluded that the antiplatelet strategy following PFO closure did not seem to impact clinical outcomes, thus challenging the current recommendations of temporary DAPT. Prasugrel and ticagrelor, 2 potent P2Y12-inhibitors, offer a more effective platelet inhibition compared to the prior gold-standard drug, clopidogrel. However, this improved efficacy comes with an increased risk of bleeding.5 Dr Komócsi and co-workers present data from a sub-study of the TROPICAL-acute coronary syndromes (ACS) trial6 aimed to determine the impact of body mass on the efficacy of platelet-function testing-guided de-escalation regimen in ACS patients after percutaneous coronary intervention (PCI). They report that the strategy of guided DAPT de-escalation was associated with a significant net clinical benefit in non-overweight patients, while the 2 strategies were equivalent in overweight patients. Bleeding complications to DAPT have an important prognostic impact in patients with ACS and are associated with short- and long-term mortality.7–10 In a Danish study, the authors aimed to characterize and follow patients with ST-segment elevation myocardial infarction (STEMI) at high bleeding risk (HBR) according to the PRECISE-DAPT score (predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy), and to examine the use of P2Y12-inhibitors and subsequent risk of major adverse cardiovascular events and bleeding. This single-center cohort study included 6179 consecutive STEMI patients who underwent PCI at Copenhagen University Hospital, between 2009 and 2016. The study reported that one-third of PCI-treated all-comer patients with STEMI were at HBR according to the PRECISE-DAPT score and more often treated with potent P2Y12-inhibitors instead of clopidogrel. Thus, ischaemic risk may be weighted over bleeding risk in STEMI patients at HBR. Ticagrelor is associated with a lower risk of ischaemic events than clopidogrel. However, it is uncertain whether the benefits of more intensive anti-ischaemic therapy outweigh the risks of major bleeding in patients who have a HBR. Therefore, a Swedish group compared ticagrelor and clopidogrel in myocardial infarction (MI) patients with HBR using Swedeheart data. They observed no difference in net adverse clinical events when comparing ticagrelor and clopidogrel in HBR patients. Moreover, they found no statistically significant interactions between bleeding risk and the comparative effectiveness of clopidogrel and ticagrelor in a larger population of MI patients. In addition, another option has been examined, with platelet P2Y12 inhibiting therapy in adjunct to vascular dose of rivaroxaban or aspirin: a pharmacodynamic study of dual pathway inhibition vs. DAPT.11–15 Higher rates of thrombotic events have been reported in MI patients requiring blood transfusion.16 The impact of blood transfusion strategy on thrombosis and inflammation is still unknown. Dr Steg et al. aimed to compare the impact of a liberal vs. a restrictive transfusion strategy on P2Y12 platelet reactivity and biomarkers in the multicentric randomized REALITY trial. They concluded that a conclusion should be tempered due to a lower number of patients with exploitable biological data that has affected their power to show a difference. To compare the impact of a liberal vs. a restrictive transfusion strategy on P2Y12 platelet reactivity and biomarkers in the multicentric randomized REALITY trial. Patients were randomized to a liberal (haemoglobin ≤10 g/dL) or a restrictive (haemoglobin ≤8 g/dL) transfusion strategy had VASP-PRI platelet reactivity measured centrally in a blinded fashion and PRU measured locally using encrypted VerifyNow; at baseline and after randomization. In the present study, the authors did not find a significant impact of red blood cell transfusion on platelet reactivity and systemic biomarkers in patients with anaemia and acute MI. The authors say these reassuring data on the effect of blood transfusion on platelet reactivity should not be interpretated as an argument to support a liberal transfusion strategy, to provide an improvement of anaemic patient symptoms and quality of life, as it is a rare and expensive resource, and we should wait for the results of the MINT trial to obtain robust clinical data of 3 this strategy. Out-of-hospital cardiac arrest (OHCA) remains an elusive public health burden in Western societies, accounting for up to 50% of all cardiovascular deaths and up to 20% of all natural deaths.17 In a Danish cohort study, the authors aimed to examine if Methylphenidate, a sympathomimetic drug prescribed to treat attentiondeficit/hyperactivity disorder, was associated with cardiovascular events. The study group found that Methylphenidate use was associated with an increased risk of OHCA in the general population. This increased risk applies to both sexes and is independent from age and the presence of cardiovascular disease.