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.
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| 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