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BLOG: Emerging pharmacological concepts at EuroPCR
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PARIS — With many questions remaining as to the optimal anticoagulant strategy for patients undergoing PCI and the utility of platelet function testing in general, Dominick J. Angiolillo, MD, PhD, discusses these issues that came up recently at EuroPCR, as well as the trials that may provide further insight on these pharmacological conundrums.
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Thursday at EuroPCR we had a very interesting session dealing with possible problems in patients undergoing PCI, in particular patients requiring anticoagulation. This is a big problem because of the limited data on how to effectively manage these patients. There have been consensus documents in the past, both from North America and Europe, but it was not until recently that we had a clinical trial, WOEST, which really introduced the new concept of stopping aspirin in these patients. This was something for decades, particularly in the interventional community, we would have never considered; however, WOEST has shown that not only is it a safer strategy, but also there are very clear signals that aspirin cessation can be beneficial in reducing ischemic events.
Dominick J. Angiolillo
And so what has emerged is that there is definitely more to be done. There is now a series of new trials that will apply the concept of dropping aspirin, including PIONEER, GLOBAL LEADERS and COMPASS, which I look forward to learning about in the near future.
Another emerging concept here involves the new oral anticoagulants, which are being more broadly utilized. The uptake of these agents compared with new antiplatelet agents has been quite remarkable because the comparator is warfarin, which is not the best drug to deal with. So we are now faced with the problem of not knowing how to manage these patients. We do now have some dedicated trials examining this, so it is a very interesting moment because we are trying to face old problems with new drugs.
A third emerging concept has been with the new agents and the disappointing results of platelet function testing trials, most recently ARCTIC. Questions remain as to where we should go with this field and whether it is really over. The general consensus is that there has been diminishing enthusiasm in the field and the data do reflect what the guidelines say so far, which argue against routine use. But there is also a general agreement that there is still some hope. Perhaps the main problem is that although we have three nicely done prospective, randomized studies, they all have several major limitations. So we have not yet had the ideal trial to address the question. At this point in time, we know where the errors have been with the past trials, we just need to design a dedicated trial to define whether there is still a role for platelet function testing in clinical practice.
So this has been the general consensus and conclusion of a very interesting and dedicated session on practicalities of antiplatelet/anticoagulant management in specific settings of PCI and trying to understand how to balance safety and efficacy.