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Find Out Why De-escalation of Dual Antiplatelet Therapy Is The Most Effective Approach in Acute Coronary Syndrome Treatment, Study Reveals

A recent study has revealed that the de-escalation of dual antiplatelet therapy or DAPT is the most effective approach for the treatment of acute coronary syndrome or ACS, which leads to fewer bleeding events without increasing ischemic events, compared with established uses of DAPT.

Find Out Why De-escalation of Dual Antiplatelet Therapy Is The Most Effective Approach in Acute Coronary Syndrome Treatment, Study Reveals
Photo: A Myocardial Infarction | InStyleHealth

What Is Acute Coronary Syndrome?

Acute Coronary Syndrome or ACS is a medical term describing various conditions correlated with sudden, reduced blood flow to the heart.

Most common condition is the heart attack or the myocardial infarction. This happens when cell death results in damaged or destroyed heart tissues. Even though acute coronary syndrome causes no cell death, reduction of blood flow changes how the heart works and is a sign of a high risk of a pending heart attack.

Acute Coronary Syndrome often causes severe chest pain or discomfort. This is a medical emergency which requires immediate diagnosis and care. The treatment of acute coronary syndrome aims to improve blood flow, treating potential complications and preventing future cardiovascular related events.

What Are The Symptoms of Acute Coronary Syndrome?

Acute Coronary Syndrome has signs and symptoms that usually start suddenly. These symptoms are the following:

  • Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning
  • Feeling restless or apprehensive
  • Indigestion
  • Lightheadedness, dizziness or fainting
  • Nausea or vomiting
  • Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw
  • Shortness of breath (dyspnea)
  • Sudden, heavy sweating (diaphoresis)
  • Unusual or unexplained fatigue

A chest pain or chest discomfort is the prevalent symptom of acute coronary syndrome. Though, ACS signs and symptoms may vary significantly depending on age, gender, and other medical conditions or comorbidities. A person is more likely to have signs and symptoms without the chest pain or discomfort if you’re a woman, older adult or have Type 1 or Type 2 diabetes.

What Are The Causes of Acute Coronary Syndrome?

Causes of acute coronary syndrome usually are results from the buildup of fatty deposits or known as ‘plaques’ in and on the walls of coronary arteries, the blood vessels delivering oxygen and nutrients to the heart muscles.

However, when the plaque deposits rupture or split, a blood clot forms. This blood clot will block the flow of blood to the heart muscles.

This blockage further causes the supply of oxygen to cells to getting too low, the cells of the heart muscles will die. Death of the cells of the heart muscles will result in damage to muscle tissues, therefore a cardiovascular event takes place known as heart attack or myocardial infarction.

Even when there is no cell death that takes place, the decrease in oxygen will still result in heart muscles that will not work the way these heart muscles should. This change can be temporary or can even become permanent. So, when acute coronary syndrome does not result in cell death, it is called unstable angina.

What Are The Risk Factors for Acute Coronary Syndrome?

Acute coronary syndrome carries risk factors which are the same as those for other types of cardiovascular or heart diseases. Acute coronary syndrome risk factors include the following:

  • Aging
  • Cigarette smoking
  • COVID-19 infection
  • Diabetes
  • Family history of chest pain, heart disease or stroke
  • High blood cholesterol
  • High blood pressure
  • History of high blood pressure, preeclampsia or diabetes during pregnancy
  • Lack of physical activity
  • Obesity or overweight
  • Unhealthy diet

What Is Dual Antiplatelet Therapy or DAPT?

Dual antiplatelet therapy (DAPT), is technically defined as the use of a P2Y12 receptor inhibitor such as clopidogrel, ticagrelor or prasugrel and aspirin, is required after percutaneous coronary intervention (PCI) with drug-eluting stents (DES).

What Is Dual Antiplatelet Therapy Used For?

The usage of DAPT or the dual antiplatelet therapy lowers the current ischemic events, including stent thrombosis, at the expense of bleeding complications when compared with aspirin alone. Dual antiplatelet therapy or DAPT with aspirin and a P2Y12-receptor antagonist plays a crucial role in the secondary prevention following an acute coronary syndrome.

Researchers sought to compare the efficacy and safety results of various DAPT strategies in ACS patients, including the de-escalation from a potent P2Y12 inhibitor to clopidogrel or low-dose prasugrel. Experts searched Medline and Embase through January 2021 for randomized controlled trials or RCTs examining the efficacy and safety of DAPT in ACS patients and conducted a network meta-analysis.

The composite of cardiovascular death, myocardial infarction, and stroke was the primary efficacy result. Primary bleeding result was defined as either major or minor bleeding.

There were 15 RCTs, including a total of 55,798 patients with ACS, met the eligibility criteria. The de-escalation therapy resulted in a reduced risk of primary bleeding results vs clopidogrel vs ticagrelor vs standard-dose prasugrel, vs low-dose prasugrel, with no negative effects on primary efficacy results.

There was not significant differences were observed in ischemic or bleeding results between de-escalation to clopidogrel or low-dose prasugrel.

Researchers said that balancing the effects of DAPT in the era of potent P2Y12 inhibitors has become a cornerstone of ACS management. Recent RCTs have investigated DAPT de-escalation to decrease the risk of bleeding outcomes.


Source: J Am Coll Cardiol 2021;78:763-777

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