Adjunctive Therapy for Cardiovascular Intervention — Its Time Has Come

It is with great excitement that The Journal of Invasive Cardiology will be initiating a new section called “Adjunctive Therapy.” While much of the focus of cardiovascular intervention relies upon mechanical approaches to improve perfusion, it has become clear in recent years that adjunctive pharmacotherapy is critical to improve upon the results obtained by mechanical means alone. Specific examples include the introduction of the intravenous glycoprotein IIb/IIIa inhibitors and more recently the direct thrombin inhibitor bivalirudin.^1,2 Indeed, without the incorporation of dual antiplatelet therapy with aspirin plus clopidogrel, the current era of liberal stent implantation would not be possible. Beyond the role of peri-procedural antithrombotic therapy, recent trials such as PCI-CURE and CREDO have shown the importance of prolonged antithrombotic therapy in patients who have undergone interventional procedures.^3,4 Furthermore, the purview of the interventional cardiologist now extends beyond managing antithrombotic strategies of patients undergoing intervention to focus also on plaque modification and perhaps even plaque regression. Clinical trials such as REVERSAL and PROVE-IT have validated the role of early and potent statin therapy in patients presenting with ischemic syndromes.^5,6 Prior observational studies had suggested that patients undergoing percutaneous revascularization benefited from statin therapy prior to the interventional procedure as opposed to only afterwards.^7,8 This concept of statin pretreatment has now been validated in a randomized clinical trial, the ARMYDA trial.⁹ Therapies specifically targeting inflammation will likely be developed as well.^10,11 Thus, the role of medical therapy in the care of patients with atherothrombotic disease has now been found to be entirely complimentary to endovascular strategies. This hybrid approach to treating vascular disease, that is the use of polypharmacy along with endovascular intervention, will likely become the predominant paradigm for the care of patients with atherothrombotic disease involving the coronary, peripheral and cerebrovascular circulations.^12,13 While much has been accomplished in the development of pharmacological adjuncts to the care of interventional patients, there are still several exciting avenues of research that are being pursued.¹⁴ For the curious mind, it is always possible to build a better mousetrap. It is the goal of this section to provide readers with the current state-of-the-art in comprehensive review articles, but also to identify potential advances in pharmacotherapy with original research papers. Examples include the intravenous ADP receptor antagonist cangrelor as well as the various Factor Xa inhibitors that are in development such as otamixaban. Furthermore, better chronic therapies such as to aid in the fight against tobacco abuse and obesity are being developed. A prime example is the endocannabinoid receptor antagonist rimonabant. Further along the developmental spectrum, gene-based therapies and progenitor cell infusions may ultimately find their way into common clinical practice.¹⁵ And, of course, mechanical adjuncts to interventional procedures such as embolic protection devices and hybrid pharmaco-mechanical therapies such as stents that serve as vectors for drug or gene delivery may also ultimately bear out as useful in interventional cardiovascular medicine. Thus, through both state-of-the-art review articles and original research papers, the adjunctive therapy section hopes to lend a different perspective and new dimension to the comprehensive care of patients undergoing interventional procedures.

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