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Role of antithrombotic therapy evolving
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BOSTON — The past year has seen much new research about antithrombotic therapy for primary prevention, secondary prevention and after PCI, according to a speaker at the Cardiometabolic Health Congress.
Cardiology Today’s Intervention Chief Medical Editor Deepak L. Bhatt, MD, MPH, executive director of interventional cardiovascular programs at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, said recent data have indicated that:
- Dual antiplatelet therapy for 1 year remains the best course of action after ACS.
- The role of aspirin in primary prevention has been called into question.
- In patients with atrial fibrillation who undergo PCI, triple therapy of an anticoagulant, a P2Y12 inhibitor and aspirin confers high bleeding risk, so double therapy, usually dropping aspirin, is a safer bet.
- There is now a role for antiplatelet therapy plus low-dose anticoagulation.
The GLOBAL LEADERS study of patients who had PCI was designed to test whether an experimental strategy of aspirin plus ticagrelor (Brilinta, AstraZeneca) for 1 month followed by ticagrelor alone would produce better outcomes than the standard strategy of DAPT for 1 year followed by aspirin alone, but there was no significant difference in death or MI at 2 years, Bhatt said.
“Aspirin is still the global leader in antiplatelet therapy,” he said, but noted that the TWILIGH trial is testing other versions of these antithrombotic strategies in this population.
He also noted that in the ASCEND trial of aspirin for primary CVD prevention in patients with diabetes but no diagnosed atherosclerosis, “The trial met its primary endpoint with a significant reduction in major atherosclerotic and vascular events, with a little over 1% absolute risk reduction. It was publicized as a negative trial [because aspirin was associated with increased bleeding events], but I think it was a positive trial. I don’t know that I would equate a [gastrointestinal] bleed to an MI. The bottom line is, I think there is something here. For some patients with diabetes at particularly high risk, even though they may not carry a diagnosis of atherosclerosis, aspirin could play an important role. This emphasizes the importance of shared decision-making; there is a lot of gray here.”
Until recently, triple therapy was the standard of care for patients with AF after PCI, but due to bleeding risk, several studies have tested whether double therapy of an oral anticoagulant plus a P2Y12 inhibitor would be safer, Bhatt said.
A meta-analysis published in the European Heart Journal found that dual-therapy strategies were associated with reduced risk for TIMI bleeding compared with triple therapy, without any apparent increase in risk for death or thrombotic events, Bhatt noted.
Also of note, he said, the COMPASS trial showed that a low dose of the factor Xa inhibitor rivaroxaban (Xarelto, Janssen/Bayer) plus aspirin reduced risk for CV death, stroke and MI but increased risk for major bleeding compared with aspirin alone in patients with stable CAD or peripheral artery disease. However, he said, when the ischemic and bleeding events were analyzed together, the rivaroxaban plus aspirin strategy had a net clinical benefit vs. the aspirin-alone strategy.
The results of COMPASS appear to be generalizable, as more than half of the patients in the REACH registry would have been eligible for inclusion in COMPASS, Bhatt said.
“As Eugene Braunwald, MD, wrote in the editorial, COMPASS is a very important step for thrombocardiology,” he said. – by Erik Swain
References:
Bhatt DL. FDA Update and Late-Breaking Clinical Trials. Presented at: Cardiometabolic Health Congress; Oct. 24-27, 2018; Boston.
ASCEND Study Collaborative Group. N Engl J Med. 2018;doi:10.1056/NEJMoa1804988.
Eikelboom JW, et al. N Engl J Med. 2017;doi:10.1056/NEJMoa1709118.
Golwala HB, et al. Eur Heart J. 2018;doi:10.1093/eurheartj/ehy162.
Vranckx P, et al. Lancet. 2018; doi:10.1016/S0140-6736(18)31858-0.
Disclosure: Bhatt reports he has financial ties with numerous pharmaceutical and device companies.