CONTROVERSIES IN ANTIPLATELET AND ANTICOAGULANT THERAPY
Deepak L. Bhatt, M.D., Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
Antiplatelet therapy is critical for patients with acute coronary syndromes, those undergoing coronary stenting, and especially for patients with both indications. Aspirin continues to be the backbone of antiplatelet strategies in cardiovascular secondary prevention. The concept of dual antiplatelet therapy – that is, aspirin plus an adenosine diphosphate receptor antagonist – has been a major advance in secondary prevention. Specifically, dual antiplatelet therapy is indicated for a year after an acute coronary syndrome. The most recent data support use of dual antiplatelet therapy even beyond a year in high risk patients with a history of prior myocardial infarction, assuming that they are at low bleeding risk. In patients without acute coronary syndromes who have received stents, the optimal duration of dual antiplatelet therapy remains a controversial point. Studies are ongoing to determine if second generation drug eluting stents may require a shorter mandated duration of dual antiplatelet therapy. Beyond the controversies of duration of dual antiplatelet therapy, physicians remain uncertain about which patients benefit most from intensification of the antiplatelet regimen, either with oral or intravenous agents. The major challenge remains balancing reductions in ischemic events with increases in bleeding. No antiplatelet agent has yet succeeded in uncoupling anti-thrombotic benefit from bleeding hazards. Perhaps no area is as challenging in this regard as the management of patients with acute coronary syndromes and atrial fibrillation. Major randomized clinical trials are underway to determine the best combinations and durations of antiplatelet and anticoagulant therapies in this cohort of patients.