Adjunctive Antiplatelet Treatment in Primary Percutaneous Coronary Intervention

Abstract

Background: Despite significant advances in the management of coronary heart disease, myocardial infarction is still associated with high mortality. Thienopyridines and glycoprotein IIb/IIIa inhibitors have been used extensively in the management of ST segment elevation myocardial infarction.
Objective: This article discusses the evidence from clinical trials and registries concerning the benefits of thienopyridines, reviews the results of published multicenter, randomized controlled trials of the efficacy and safety of platelet GPIIb/IIIa inhibitors in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention (PCI) and presents the recent guidelines.
Methods: Data for this review were identified by broad searches of MEDLINE, Current Contents and references from relevant articles (1980-2011); numerous articles were identified through searches of the extensive files of the authors and selected based on their importance, oppurtunity for further reading and up to date information. Search terms included thienopyridines, platelet aggregation inhibitors, percutaneous coronary intervention, antiplatelet therapy, ST elevation myocardial infarction (STEMI), primary percutaneous coronary intervention. Only English language papers were reviewed. No restrictions were set on the type of papers.
Results: Clopidogrel is the most commonly used thienopyridine in patients undergoing primary PCI. Recently new inhibitors of P2Y12 receptors, like prasugrel and ticagrelor, have become available, which have a more potent and rapid onset of action, with similar safety profile, which is specifically targeted to the subgroup of primary PCI. On the other hand, the platelet glycoprotein IIb/IIIa inhibitors have aided and abetted medical management of acute coronary syndromes and proved an important adjunctive therapy in percutaneous coronary interventions. Platelet glycoprotein IIb/IIIa inhibitors, although not recommended for routine therapy, have an important role at the time of primary PCI, particularly in high-risk subgroups, like the diabetics and those with a heavy thrombotic burden.
Conclusion: Clopidogrel remains the most used thienopyridine together with aspirin in patients undergoing primary PCI but there are currently available new inhibitors of P2Y12 receptors, like prasugrel and ticagrelor, which have a more potent and rapid onset of action, with similar safety profile. Glycoprotein IIb/IIIa antagonists, although not recommended for routine therapy, can be of use at the time of primary PCI, particularly in high-risk subgroups.