Top Things to Know: 2012 Focused Update of the Guideline for Management of Patients With Unstable Angina NSTEMI
Published: July 16, 2012
- Since the publication of the 2011/2007 guidelines, the FDA has approved two additional P2Y12 receptor inhibitors—prasugrel and ticagrelor—for use in patients with UA/NSTEMI as a component of antiplatelet therapy.
- This guideline does not endorse one P2Y12 inhibitor over the other. These therapies have been added to the guideline recommendations in an effort to guide comprehensive therapy alternatives.
- Response to clopidogrel varies among patients, and diminished responsiveness to clopidogrel has been observed. The optimal loading and short-term maintenance dosing for clopidogrel in patients with UA/NSTEMI undergoing PCI is uncertain.
- Ticagrelor and prasugrel have been studied in different patient populations and during the process of developing this focused update there has yet to be a head-to-head comparative trial between these agents.
- Studied separately in comparison to clopidogrel, prasugrel and ticagrelor were superior to clopidogrel in reducing clinical events but at the expense of increased risk of bleeding.
- Considerations of efficacy in the prevention of thrombosis, risk of an adverse effect related to bleeding, and experience with a given medication may best guide decisions about the choice of P2Y12 inhibitor for individual patients.
- In the studies cited, prasugrel was administered only after a decision to proceed to percutaneous coronary intervention (PCI) was made, where ticagrelor was studied in all-comer patients with UA/NSTEMI.
- Although the composite efficacy endpoint in TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel–Thrombolysis in Myocardial Infarction) favored prasugrel, due to differences in nonfatal MIs (mostly asymptomatic), bleeding was increased in the prasugrel group.
- The composite efficacy endpoint in PLATO (A Comparison of Ticagrelor and Clopidogrel in Patients With Acute Coronary Syndrome) favored ticagrelor over clopidogrel due to differences in both vascular death and nonfatal MIs. Compared with clopidogrel, ticagrelor was associated with a higher rate of non-CABG related major bleeding, and slightly more frequent discontinuation of the study drug due to adverse events.
- Important considerations in stroke and transient ischemic attack (TIA)
a. For patients with a history of stroke or TIA for whom PCI is planned, prasugrel is potentially harmful as part of a dual antiplatelet therapy regimen.
b. Prior to administration of ticagrelor, consideration should be given to the potential, and as yet undetermined, risk of intracranial hemorrhage in patients with prior stroke or TIA.
Citation
Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE Jr, Ettinger SM, Fesmire FM, Ganiats TG, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non–ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012: published online before print July 16, 2012, 10.1161/CIR.0b013e318256f1e0.