Combination antiplatelet treatment in coronary artery disease patients: A necessary evil or an overzealous practice?

Abstract

In seeking to improve care in coronary artery disease patients, further platelet inhibition has been occasionally applied beyond that provided by aspirin and a P2Y receptor antagonist. This review aims to offer insights about the rationale, the efficacy and safety of combination antiplatelet therapy, involving three or more agents. Overall, the use of glycoprotein (GP) IIb/IIIa inhibitors did not significantly modify the treatment effect of different antiplatelet strategies, including double vs standard clopidogrel, prasugrel vs clopidogrel, ticagrelor vs clopidogrel, cangrelor vs clopidogrel, and vorapaxar vs placebo. With the caveat that the use of GP IIb/IIIa inhibitor was not randomized, adding such an agent to aspirin and a P2Y receptor antagonist appears to carry a significantly increased bleeding potential. Moreover, adding vorapaxar to aspirin- and clopidogrel-treated patients is associated with more bleeding events, while the bleeding potential is further exacerbated in cases of quadruplicate antiplatelet treatment including aspirin, clopidogrel, vorapaxar, and a GP IIb/IIIa inhibitor. In ST-segment elevation, myocardial infarction patients' administration of an intravenous antiplatelet agent (GP IIb/IIIa inhibitor or cangrelor), in addition to aspirin and a P2Y receptor antagonist, efficiently bridges the pharmacodynamic gap of oral agents. Cilostazol on top of aspirin and clopidogrel appears to be safe, although of questionable clinical benefit. In conclusion, combination antiplatelet therapy should be reserved only for selected cases and following thoughtful consideration of the associated risk/benefit ratio.

Antiplatelet Therapy with Integrated Traditional Chinese and Western Medicine for Use in Myocardial Ischemia-Reperfusion Injury: A Review of Clinical Applications and Mechanisms

“…ree GP IIb/IIa inhibitors are abciximab, tirofiban, and eptifibatide. Among them, abciximab is the most studied GP IIb/IIa inhibitor [37]. Basic research [27] found that GP IIb/IIIa inhibitors have the potential to treat MIRI.…”

Highlights from the 2019 International Aspirin Foundation Scientific Conference, Rome, 28 June 2019: benefits and risks of antithrombotic therapy for cardiovascular disease prevention

“…The number needed to treat with a PPI in order to avoid a disabling bleed is over 300 in younger populations but this figure drops to around 25 in older adults. It is important to carefully consider the likely risk versus benefit of each antiplatelet and how many antiplatelets are required when selecting a treatment regimen for patients [41]. Platelet function tests may help to facilitate the choice of antiplatelet therapy [42,43].…”

Antiplatelets, Anticoagulants and Its Implications in Dentistry-A Review of Literature

“…A 2015 systematic review of management of dental extractions in patients receiving warfarin determined that patients whose International Normalized Ratio (INR; a measure of warfarin's therapeutic index) was in therapeutic range (i.e., 3.0 or less) could continue their regular warfarin regimen prior to the procedure [42].Some of the recent drugs used are Cilostazol on top of aspirin and clopidogrel appears to be safe, although of questionable clinical benefit. In conclusion, combination antiplatelet therapy should be reserved only for selected cases and following thoughtful consideration of the associated risk/benefit ratio [45].…”