Antiplatelet and anticoagulant agents: key differences in mechanisms of action, clinical application, and therapeutic benefit in patients with non-ST-segment-elevation acute coronary syndromes.

摘要

PURPOSE OF REVIEW: Platelet activation and aggregation are important pathophysiologic elements of both non-ST-elevation acute coronary syndromes and the ischemic complications of percutaneous coronary intervention, making antiplatelet agents necessary components of the pharmacotherapeutic treatment paradigm for these patients. This review evaluates and interprets the role of oral antiplatelet agents, glycoprotein IIb-IIIa inhibitors, and bivalirudin in the context of current clinical evidence and practice. RECENT FINDINGS: The current standard of care for patients with non-ST-elevation acute coronary syndromes--aspirin, clopidogrel, and glycoprotein IIb-IIIa inhibitors for the majority of patients--is being challenged by recent clinical trials (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment, Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 2, Randomized Evaluation of Percutaneous coronary intervention Linking Angiomax to Reduced Clinical Events-2, Acute Catheterization and Urgent Intervention Triage StrategY), raising important questions regarding the value of glycoprotein IIb-IIIa inhibitors as accompaniments of high-dose clopidogrel pretreatment and increased use of the anticoagulant bivalirudin. SUMMARY: Current data indicate that antiplatelet regimens consisting of aspirin, clopidogrel, and a glycoprotein IIb-IIIa inhibitor provide substantial benefit among patients who undergo percutaneous coronary intervention. Optimized antiplatelet and anticoagulant therapy--including aspirin, clopidogrel, a glycoprotein IIb-IIIa inhibitor, and an anticoagulant--may reduce the incidence of subclinical and clinical events.