The Role of Clopidogrel in 2020: A Reappraisal

Abstract

Antiplatelet therapy is the mainstay of treatment and secondary prevention of cardiovascular disease (CVD), including acute coronary syndrome (ACS), transient ischemic attack (TIA) or minor stroke, and peripheral artery disease (PAD). The P2Y12 inhibitors, of which clopidogrel was the first, play an integral role in antiplatelet therapy and therefore in the treatment and secondary prevention of CVD. This review discusses the available evidence concerning antiplatelet therapy in patients with CVD, with a focus on the role of clopidogrel. In combination with aspirin, clopidogrel is often used as part of dual antiplatelet therapy (DAPT) for the secondary prevention of ACS. Although newer, more potent P2Y12 inhibitors (prasugrel and ticagrelor) show a greater reduction in ischemic risk compared with clopidogrel in randomized trials of ACS patients, these newer P2Y12 inhibitors are often associated with an increased risk of bleeding. Deescalation of DAPT by switching from prasugrel or ticagrelor to clopidogrel may be required in some patients with ACS. Furthermore, real-world studies of ACS patients have not confirmed the benefits of the newer P2Y12 inhibitors over clopidogrel. In patients with very high-risk TIA or stroke, short-term DAPT with clopidogrel plus aspirin for 21–28 days, followed by clopidogrel monotherapy for up to 90 days, is recommended. Clopidogrel monotherapy may also be used in patients with symptomatic PAD. In conclusion, there is strong evidence supporting the use of clopidogrel antiplatelet therapy in several clinical settings, which emphasizes the importance of this medication in clinical practice.

Efficacy and safety of newer P2Y12 inhibitors for acute coronary syndrome: a network meta-analysis

“…Ticagrelor, with its better safety profile, should be considered over clopidogrel in most ACS patients. Although, current observational studies reporting inconsistent results do not confirm the superiority of newer P2Y 12 inhibitors over clopidogrel in ACS patients receiving PCI 51 , they are prone to bias and should be interpreted with caution given the potential for confounding. Nevertheless, real-world studies are helpful in translating the findings from RCTs into practice settings in the general population.…”

The Role of Genetic Polymorphism and Other Factors on Clopidogrel Resistance (CR) in an Asian Population with Coronary Heart Disease (CHD)

“…Some patients can also develop recurrent ischemic events such as stent thrombosis and myocardial infarction during treatment with clopidogrel. This failure of platelet aggregation inhibition in clopidogrel users is referred to as clopidogrel resistance (CR) or platelet hyperresponsiveness [ 11 , 12 , 13 ]. Studies have shown that 4 to 30% of patients have CR, and 5 to 6% of patients have DAPT resistance after implanting the stent [ 14 , 15 ].…”

MicroRNA as Potential Biomarkers of Platelet Function on Antiplatelet Therapy: A Review

“…Patients with HTPR are known to present with a significantly higher risk of CV death, MI, and ST post-PCI (Aradi et al, 2010). Despite many disadvantages of clopidogrel administration, newer P2Y12 inhibitors-prasugrel and ticagrelor, often come with increased risk of bleeding, which in some patients, leads to the need to de-escalate the therapy with clopidogrel (Patti et al, 2020). Thus, monitoring of patients on DAPT with clopidogrel, more comprehensive understanding of interindividual difference in response to clopidogrel treatment, together with more advanced platelet-function monitoring techniques, could be beneficial in the prevention of adverse thrombotic outcomes (Aradi et al, 2010).…”