Abstract
The platelet is central to the pathogenesis of acute coronary syndromes (ACS), and antiplatelet therapy has demonstrated a significant reduction in the risk for ischemic events in patients with ACS. For patients with unstable angina or non–ST elevation myocardial infarctions, regardless of whether a conservative or invasive (i.e., percutaneous intervention) treatment approach is used, current guidelines recommend combination antiplatelet therapies, including aspirin with the thienopyridines clopidogrel or prasugrel and/or a glycoprotein IIb/IIIa inhibitor. However, there remains a significant incidence of arterial thrombosis in patients receiving currently available antiplatelet therapy, indicating the need for improved and/or alternative agents and targets. Recent landmark clinical trials of new oral antiplatelet therapies, including the thienopyridine prasugrel and the investigational reversible oral adenosine diphosphate antagonist ticagrelor, indicate they have a faster onset of action, result in a more predictable response, and provide improved efficacy compared to clopidogrel, the current standard of care. Other promising potential targets under investigation to reduce the contribution of the platelet to ACS pathophysiology include von Willebrand factor, thromboxane A 2 , and protease-activated receptor–1. Of these, the protease-activated receptor–1 antagonist vorapaxar (SCH 530348) is furthest along in clinical development, with phase II data showing profound inhibition of platelet aggregation and a large phase III development program under way. A fundamental lingering issue is whether improved prevention and treatment of thrombosis can be separated from an increase in hemorrhage or bleeding, and clinicians must continue to consider the potential risks and benefits when individualizing antiplatelet therapy for patients with ACS.
Online Access: http://cmeaccess.com/cme/ajc_acs_program/
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Author Disclosures
Richard C. Becker, MD , has received grants and research support from AstraZeneca, Bayer Pharmaceuticals, Bristol-Myers Squibb, Johnson & Johnson, The Medicines Company, Momenta Pharmaceuticals, Regado Biosciences, Inc., and the Schering-Plough Research Institute.
C. Michael Gibson, MS, MD , has received grants and research support from Abbott, Angel Medical Corporation, AstraZeneca, Atrium Medical Systems, Baxter Healthcare, Bayer Corporation, FibroGen, Inc., FoldRx, Genentech, Inc., Heartscape Technologies, Ikaria, Inc., Johnson & Johnson, Lantheus Medical Imaging, Portola Pharmaceuticals, Sanofi-Aventis, and Schering-Plough Corporation. He is a member of the speakers’ bureau of Daiichi Sankyo Company, Inc., Eli Lilly & Company, Schering-Plough Corporation, and The Medicines Company. He is a consultant for Acusphere, Inc., Archemix Corporation, Ascenta Therapeutics, Bayer Corporation, Heartscape Technologies, Inc., ICON Medical Imaging, Jim Moran Heart and Vascular Research Institute, Johnson & Johnson, Medicure, Inc., Novartis Pharmaceutical Corporation, Portola Pharmaceuticals, Inc., Sanofi-Aventis, Schering-Plough Corporation, St. Jude Medical, and The Medicines Company. Dr. Gibson has received royalties as a contributor for Pocket Medicine and UpToDate in Cardiovascular Medicine.
Lisa K. Jennings, PhD , is a consultant and speaker for Schering-Plough Corporation, Bristol-Myers Squibb/Sanofi-Aventis, and Portola Pharmaceuticals. She is a member of the advisory board for Schering-Plough Corporation, Bristol-Myers Squibb/Sanofi-Aventis, and Eli Lilly & Company.
David A. Morrow, MD, MPH , has received grants and research support from Accumetrics, AstraZeneca, Bayer Healthcare, Beckman Coulter, Inc., Bristol-Myers Squibb, CV Therapeutics, Daiichi Sankyo Company, Inc., Eli Lilly & Company, Genentech, Inc., Inotek Pharmaceuticals, Integrated Therapeutics, Johnson & Johnson, Merck & Company, Inc., Merck-Schering-Plough Joint Venture, Nanosphere, Novartis Pharmaceuticals Corporation, Nuvelo, Ortho-Clinical Diagnostics, Pfizer, Inc., Roche Diagnostics, Sanofi-Aventis, Siemens Medical Solutions, Singulex, and Schering-Plough Corporation. He is a consultant and a member of the advisory board for AstraZeneca, Beckman Coulter, Inc., Molecular Insight, Sanofi-Aventis, Schering-Plough Research Institute, and Siemens Medical Solutions. Dr. Morrow has received honoraria from CV Therapeutics and Eli Lilly & Company for educational presentations.
Acknowledgment
This CME Multimedia Activity was peer reviewed by The American Journal of Cardiology and jointly sponsored by the Purdue University College of Pharmacy and Health Education Alliance, Inc .
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