Anti-platelet therapies

  • Anthony A Bavry
  • Deepak L Bhatt


Anti-platelet drugs are one of the fundamental therapies for improving cardiovascular outcomes among ACS patients. Medications are used adjunctively along with mechanical or chemical reperfusion. Patients who are not candidates for revascularization may only receive medical treatment for their ACS. Cardiovascular drugs are given with the expectation that they will produce a significant beneficial effect. For some drugs in certain groups of patients, the goal is to improve survival and reduce infarct size, while for other drugs the goal is the amelioration of ischemic symptoms. Drugs, like aspirin, are widely used across the spectrum of ACS, although other agents like fibrinolytics are only used in ST-elevation myocardial infarction. It is also important to understand that each drug comes with the potential for side effects. Accordingly, the risk-benefit profile for each cardiovascular drug should be known, and the side effects minimized where possible. For some patients, the risk of a drug will outweigh its expected benefit, and should therefore not be used. This chapter will review the important anti-platelet cardiovascular drugs across the spectrum of ACS and emphasize the benefits and side effects of each agent.


Percutaneous Coronary Intervention Acute Coronary Syndrome Antiplatelet Therapy Platelet Glycoprotein Sustained Dual Oral Antiplatelet Therapy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Collaborative overview of randomised trials of antiplatelet therapy — I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists’ Collaboration. BMJ 1994; 308:81–106.CrossRefGoogle Scholar
  2. 2.
    Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet 1988; 2:349–360.Google Scholar
  3. 3.
    Peters RJ, Mehta SR, Fox KA, et al.; Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Trial Investigators. Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study. Circulation 2003; 108:1682–1687.CrossRefGoogle Scholar
  4. 4.
    Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction. Circulation 2007; 116:803–877.CrossRefGoogle Scholar
  5. 5.
    Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. Circulation 2004; 110:e82–e293.CrossRefGoogle Scholar
  6. 6.
    Smith SC Jr, Feldman TE, Hirshfeld JW Jr, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Available at: Last accessed December 2007.Google Scholar
  7. 7.
    A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996; 348:1329–1339.CrossRefGoogle Scholar
  8. 8.
    Hirsh J, Bhatt DL. Comparative benefits of clopidogrel and aspirin in high-risk patient populations lessons from the CAPRIE and CURE Studies. Arch Intern Med 2004; 164:2106–2110.CrossRefGoogle Scholar
  9. 9.
    Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345:494–502.CrossRefGoogle Scholar
  10. 10.
    Mehta SR, Yusuf S, Peters RJG, et al.. Clopidogrel in Unstable angina to prevent Recurrent Events trial (CURE) Investigators. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 2001; 358:527–533.CrossRefGoogle Scholar
  11. 11.
    Sabatine MS, Cannon CP, Gibson M, et al.; Clopidogrel as Adjunctive Reperfusion Therapy (CLARITY)-Thrombolysis in Myocardial Infarction (TIMI) 28 Investigators. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. JAMA 2005; 294:1224–1232.CrossRefGoogle Scholar
  12. 12.
    Chen ZM, Jiang LX, Chen YP, et al.; COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005; 366:1607–1621.CrossRefGoogle Scholar
  13. 13.
    Helton TJ, Bavry AA, Kumbhani DJ, et al. Incremental effect of clopidogrel on cardiovascular outcomes in patients with vascular disease: a meta-analysis of randomized trials. Am J Cardiovasc Drugs 2007; 7:289–297.CrossRefGoogle Scholar
  14. 14.
    Steinhubl SR, Berger PB, Mann JT, et al.; CREDO Investigators. Clopidogrel for the Reduction of Events During Observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002; 288:2411–2420.CrossRefGoogle Scholar
  15. 15.
    Bhatt DL, Fox KAA, Hacke W, et al.; CHARISMA Investigators. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006; 354:1706–1717.CrossRefGoogle Scholar
  16. 16.
    Bhatt DL, Flather MD, Hacke W, et al.; CHARISMA Investigators. Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA Trial. J Am Coll Cardiol 2007; 49:1982–1988.CrossRefGoogle Scholar
  17. 17.
    Grines CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007; 115:813–818.CrossRefGoogle Scholar
  18. 18.
    Bavry AA, Lincoff AM. Is clopidogrel cardiovascular medicine’s double-edged sword? Circulation 2006; 113:1638–1640.CrossRefGoogle Scholar
  19. 19.
    Wiviott SD, Antman EM, Winters KJ, et al.; JUMBO-TIMI 26 Investigators. Randomized comparison of prasugrel (CS-747, LY640315), a novel thienopyridine P2Y12 antagonist, with clopidogrel in percutaneous coronary intervention: results of the Joint Utilization of Medications to Block Platelets Optimally (JUMBO)-TIMI 26 trial. Circulation 2005; 111:3366–3373.CrossRefGoogle Scholar
  20. 20.
    Wiviott SD, Braunwald E, McCabe CH, et al.; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007; 357:2001–2015.CrossRefGoogle Scholar
  21. 21.
    Bhatt DL. Intensifying platelet inhibition — navigating between Scylla and Charybdis. N Engl J Med 2007; 357:2078–2081.CrossRefGoogle Scholar
  22. 22.
    Chew DP, Bhatt DL, Sapp S, et al. Increased mortality with oral platelet glycoprotein IIb/IIIa antagonists: a meta-analysis of phase III multicenter randomized trials. Circulation 2001; 103:201–206.CrossRefGoogle Scholar
  23. 23.
    Quinn MJ, Plow EF, Topol EJ. Platelet glycoprotein IIb/IIIa inhibitors: recognition of a two-edged sword? Circulation 2002; 106:379–385.CrossRefGoogle Scholar
  24. 24.
    Bhatt DL, Topol EJ. Current role of platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. JAMA 2000; 284:1549–1558.CrossRefGoogle Scholar
  25. 25.
    Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomized clinical trials. Lancet 2002; 359:189–198.CrossRefGoogle Scholar
  26. 26.
    Roffi M, Chew DP, Mukherjee D, et al. Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes. Circulation 2001; 104:2767–2771.CrossRefGoogle Scholar
  27. 27.
    Karvouni E, Katritsis DG, Ioannidis JPA. Intravenous glycoprotein IIb/IIIa receptor antagonists reduce mortality after percutaneous coronary intervention. J Am Coll Cardiol 2003; 41:26–32.CrossRefGoogle Scholar
  28. 28.
    De Luca G, Suryapranata H, Stone GW, et al. Abciximab as adjunctive therapy to reperfusion in acute ST-elevation myocardial infarction: a meta-analysis of randomized trials. JAMA 2006; 293:1759–1765.CrossRefGoogle Scholar
  29. 29.
    Keeley EC, Boura JA, Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomized trials. Lancet 2006; 367:579–588.CrossRefGoogle Scholar
  30. 31.
    Topol EJ, Moliterno DJ, Herrmann HC, et al.; TARGET Investigators. Do Tirofiban and ReoPro Give Similar Efficacy Trial. Comparision of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. N Engl J Med 2001; 344:1888–1894.CrossRefGoogle Scholar
  31. 32.
    Wohrle J, Grebe OC, Nusser T, et al. Reduction of major adverse cardiac events with intracoronary compared with intravenous bolus application of abciximab in patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty. Circulation 2003; 107:1840–1843.CrossRefGoogle Scholar
  32. 33.
    Stone GW, Bertrand ME, Moses JW, et al.; ACUITY Investigators. Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY timing trial. JAMA 2007; 297:591–602.CrossRefGoogle Scholar
  33. 34.
    Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY trial. J Am Coll Cardiol 2007; 49:1362–1368.CrossRefGoogle Scholar

Copyright information

© Current Medicine Group, a part of Springer Science+Business Media 2008

Authors and Affiliations

  • Anthony A Bavry
    • 1
  • Deepak L Bhatt
    • 1
  1. 1.Department of Cardiovascular MedicineCleveland ClinicUSA

Personalised recommendations