Safety of antithrombotic treatment in acute coronary syndromes

September 03, 2008

The management of acute coronary syndromes (with or without ST segment elevation) requires the use of anticoagulants, antiplatelet agents (aspirin, clopidogrel and/or glycoprotein (GP) IIb/IIIa inhibitors), beta-blockers, thrombolytics in some cases, and revascularization / reperfusion.

The appropriate management of ACS has been shown over the last few decades to result in a significant improvement in outcome in the short and long term. However, the combined use of these therapies, particularly antithrombotic therapies (which include anticoagulants, antiplatelet agents and thrombolytics) may result in an excess of bleeding. Until the recent past, bleeding was not considered to be a serious complication, but over the last five years, bleeding complications have in fact emerged as a major contributor to overall risk, with a significant increase in the rate of death, myocardial infarction and stroke in patients who suffer bleeding complications during the initial phase of ACS, as compared to those who do not. In addition, blood transfusion has been shown to result in a higher risk of death, and is suspected to have deleterious effects in selected groups of patients.

The risk factors for bleeding have been well identified. Older age, female sex and low body weight have been identified as markers of the risk of bleeding. A past history of bleeding, the presence of renal failure, the use of an early invasive approach, excess dose of antithrombotic agents, and use of GP IIb/IIIa inhibitors have also been identified as strong predictors of the risk of bleeding.

Conversely, careful selection of drugs, giving precedence to drugs with less potential for bleeding, use of a radial versus femoral approach for invasive strategy, and systematic use of proton pump inhibitors to avoid gastro-intestinal bleeding during the initial phase, are all measures that have the potential to reduce the bleeding risk.

In this context, some anticoagulants have been shown to carry a lower risk of bleeding, such as fondaparinux and bivalirudin, as compared to low molecular weight heparins or unfractionated heparin. It would also appear that more consistent inhibition of platelet aggregation leads to better clinical outcome, albeit with an increased risk of bleeding.

In all, bleeding and possibly also blood transfusion have emerged as major contributors to worse outcome in patients with ACS. Proper management of patients, with appropriate selection of doses, drugs, and arterial approach, combined with systematic evaluation of the bleeding risk prior to starting therapy may help prevent bleeding and improve patient outcome.

European Society of Cardiology

---

---

	Current Guidelines on Antiplatelet Agents for Secondary Prevention of Noncardiogenic Stroke: An Evidence-Based Review (Postgraduate Medicine) by JTE Multimedia Abstract: Antiplatelet therapy is a mainstay of secondary prevention of ischemic strokes. Recent studies, such as Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS), the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial, and the European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT), have added much to our understanding about how best to utilize the various antiplatelet agents available. Aspirin has been shown to reduce the risk of recurrent strokes, and the combination of aspirin and dipyridamole has repeatedly been shown to outperform aspirin alone. Recently, clopidogrel was demonstrated to be “noninferior” to an aspirin/dipyridamole combination, and can be considered as a...
	Antiplatelet Agents (Handbook of Experimental Pharmacology) by Paolo Gresele (Editor), G.V.R. Born (Editor), Carlo Patrono (Editor), Clive P. Page (Editor) Antiplatelet therapy is the cornerstone of treatment of ischemic cardiovascular disease and over the last few years spectacular advancements in this field have been recorded. This is the first comprehensive handbook entirely dedicated to all the aspects of antiplatelet therapy. The book is divided into three main sections, pathophysiology, pharmacology and therapy, for a total of 23 chapters. A large group of leading experts from different European countries and from the USA, both from academia and industry, have contributed to the book. Besides a detailed overview on the pharmacology and clinical applications of all the currently used or of the novel antiplatelet agents, innovative approaches (e.g. intracellular signalling as an antiplatelet target, small RNAs as platelet therapeutics,...
	Antiplatelet property of Curcuma longa L. rhizome-derived ar-turmerone [An article from: Bioresource Technology] by H.S. Lee (Author) This digital document is a journal article from Bioresource Technology, published by Elsevier in 2006. The article is delivered in HTML format and is available in your Amazon.com Media Library immediately after purchase. You can view it with any web browser. Description: The antiplatelet activities of Curcuma longa L. rhizome-derived materials were measured using a platelet aggregometer and compared with those of aspirin as antiplatelet agent. The active constituent from the rhizome of Curcuma longa L. was isolated and characterized as ar-turmerone by various spectral analyses. At 50% inhibitory concentration (IC"5"0) value, ar-turmerone was effective in inhibiting platelet aggregation induced by collagen (IC"5"0, 14.4@mM) and arachidonic acid (IC"5"0, 43.6@mM). However,...
	Anticoagulants, Antiplatelets, and Thrombolytics (Methods in Molecular Biology) by Shaker A. Mousa (Editor) During the past decade, remarkable progress has been made in the development of newer drugs to prevent and treat thromboembolic disorders, such as oral direct anti-Xa and anti-IIa antagonists, as well as oral antiplatelet ADP antagonists with rapid onset and offset. In addition, there has been concentrated effort aimed at identifying novel uses of traditional antithrombotic drugs, such as aspirin, heparin, and oral anticoagulants, as well as combinations of agents, such as more than one antiplatelet, antiplatelet with anticoagulant, antiplatelet with or without thrombolytic. Anticoagulants, Antiplatelets, and Thrombolytics, Second Edition provides updates on various strategies in thrombosis, experimental models, and clinical and recent advances in the discovery and development of novel...
	Antithrombotic Drug Therapy in Cardiovascular Disease (Contemporary Cardiology) by Arman T. Askari (Editor), A. Michael Lincoff (Editor) Substantial morbidity and mortality remains associated with thrombotic events has stimulated the rapid expansion of the available armamentarium to combat pathologic thrombosis. Pathologic thrombosis plays an essential role in the pathogenesis of acute coronary syndromes (ACS), ischemic complications of percutaneous coronary intervention (PCI), venous thromboembolic disease, and embolic complications of arrhythmias and various cardiomyopathies. Written by experts in the field, Antithrombotic Drug Therapy in Cardiovascular Disease carefully examines individual and various combinations of the available antithrombotic regimens including fibrinolytic agents, antiplatelet therapies (aspirin, thieneopyridines, glycoprotein IIb/IIIa inhibitors), and anticoagulant therapies (unfractionated...
	Handbook of Compounds with Anti-Inflammatory and Anti-Platelet Aggregation Activities Isolated from Plants by Rosa Martha Perez Gutierrez (Author) This book presents 848 compounds isolated and identified from plants that present anti-inflammatory and antiplatelet aggregation activities. These substances have been classified by chemical groups and each provides the most relevant information of its pharmacological activity, action mechanism, chemical structure, spectroscopic date, and other properties. Chemical structures have been drawn to indicate the stereochemistry. In this handbook the summary of the scientific information of plants that present biological activity and the compounds responsible for these activities is presented, which introduces the reader to the study of medicinal plants and also provides bibliographic references, where a detailed study of its chemistry and pharmacology can be found.
	New Therapeutic Agents in Thrombosis and Thrombolysis, Third Edition (Fundamental and Clinical Cardiology) by Jane E. Freedman (Editor), Joseph Loscalzo (Editor) As the number of patients with thrombosis and thrombolysis increases, there is a critical need for clinicians to learn the latest scientific discoveries and treatment options. This timely Third Edition is a comprehensive text for cardiologists, hematologists, and pharmacologists in need of a resource on current agent development technology for treating cardiovascular and thromboembolic diseases. New to the Third Edition: a thorough examination of all the agents involved in treating thrombosis chapters on biomarkers, testing, and pharmacogenomics key topics, including new targets for antithrombotics, the development of novel classes of platelet inhibitors, new thrombolytic therapies, and evolving clinical uses of thrombolytics for ischemic stroke and venous thrombosis the...
	Fibrinolytic Therapy in Clinical Practice by Freek W.A. Verheugt (Editor) A major breakthrough in the treatment of cardiovascular disease, fibrinolytic therapy can provide early restoration of occluded blood vessels, thus improving symptoms and organ recovery, reducing infarct size, and improving quantity and quality of life. Explaining patient selection and providing practical guidelines, this book covers the clinical application of fibrinolytic therapy in life-threatening disorders. It covers evidence-based treatment options, examines the evolution of drug design of fibrinolytic agents, and evaluates clinical trials. It is geared for physicians taking care of acute ill patients either at intensive care units, coronary care units, or emergency departments.
	Antiplatelet Therapy In Ischemic Heart Disease (American Heart Association Clinical Series) by Stephen D. Wiviott (Author) * Draws from expertise of leaders in antiplatelet therapy * Easy-to-use layout enables rapid browsing * Edited by a member of the prestigious TIMI study group with long-standing experience in the field
	Groups address GI effects of antiplatelets, NSAIDs.(Cardiovascular Medicine)(gastrointestinal, non-steroidal anti-inflammatory drugs): An article from: Family Practice News by Sharon Worcester (Author) This digital document is an article from Family Practice News, published by International Medical News Group on November 1, 2008. The length of the article is 805 words. The page length shown above is based on a typical 300-word page. The article is delivered in HTML format and is available immediately after purchase. You can view it with any web browser. Citation Details Title: Groups address GI effects of antiplatelets, NSAIDs.(Cardiovascular Medicine)(gastrointestinal, non-steroidal anti-inflammatory drugs) Author: Sharon Worcester Publication: Family Practice News (Magazine/Journal) Date: November 1, 2008 Publisher: International Medical News Group Volume: 38 Issue: 21 Page: 10(1) Distributed by Gale, a part of Cengage...