An Antiplatelet Update

Volume 5, Issue 3

Cardiovascular disease remains the leading cause of death in the United States, even with COVID-19. A significant number of these fatalities are attributed to acute coronary syndromes (ACS), which include both STEMI and non-STEMI. Dual antiplatelet therapy (DAPT) is the cornerstone of treating acute ACS; DAPT is often continued after ACS to prevent recurrent events (although duration varies widely). In this week’s issue of Talking Therapeutics, we tackle two new papers that were published this week about antiplatelet therapy in ACS.

Point 1: Early De-escalation of DAPT May Be a Feasible Strategy to Reduce Bleeding

Historically, DAPT is continued for 1-year after ACS, although both shorter and longer durations have been explored based on patient’s risk for bleeding and stent thrombosis, respectively. Recently, the idea of de-escalating antiplatelet therapy has emerged as a means to balance these competing risks. Similar to antimicrobial stewardship, where antibiotic prescriptions are narrowed, antiplatelet de-escalation involves tapering therapy at a pre-specified time point.

A recent meta-analysis of 15 studies involving more than 55,798 patients evaluated de-escalation from a potent P2Y12 inhibitor (ticagrelor or full dose prasugrel) at one month to either clopidogrel or low-dose prasugrel. De-escalation therapy was associated with reduced risk of primary bleeding outcomes (HR: 0.32 [95% CI: 0.20-0.52] vs ticagrelor; and HR: 0.36 [95% CI: 0.24-0.55]) vs standard-dose prasugrel. The composite of cardiovascular death, myocardial infarction, and stroke was not increased with antiplatelet de-escalation.

Point 2: Success Never “Tasted” So Good…

The randomized TASTER trial tested the platelet inhibition of a 180-mg ticagrelor loading dose of an orally disintegrating tablet compared with a 180 mg standard coated tablet (SCT) in patients with ACS undergoing PCI. In the 130 patients included in the study, rates of measured platelet reactivity was similar between the two dosage forms. This was true in the highest risk patients (STEMI), as well as in patients who received morphine, which is known to delay the onset of action for ticagrelor.

These findings show that the new orally disintegrating ticagrelor tablet may offer a convenient option for ACS patients, provided that the cost for this new dosage form is not prohibitive.

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