24 Jun CARDIAC SOCIETY OF AUSTRALIA
Platelet and thrombin inhibitors Title: Study of new oral antiplatelet therapy (prasugrel, ticagrelor) in comparison with aspirin and clopidogrel to patients with Coronary ArteTo discuss the role of antiplatelet therapy in patients with CAD & ACS • To study and discuss the mechanism of action of prasugrel, ticagrelor, aspirin & clopidogrel in platelet inhibition • To discuss the adverse effects of each • To be able to compare the new oral antiplatelets (ticagrelor and prasugrel) to old antiplatelets (aspirin and clopidogrel) and the reason for its shift Platelets and thrombin inhibitors play an enormous role and impact on the fundamental management of acute coronary syndrome (ACS). The multiple trials and the research by (Chew et al., 2011) 2011 Addendum to the National Heart Foundation of Australia (NHFA)/Cardiac Society of Australia and New Zealand Guidelines for the management of Acute Coronary Syndrome (ACS) 2006, recommend, early routine angiography and revascularisation amongst patients receiving fibrinolysis, regardless of the success of pharmacologic reperfusion. In this topic we will be concentrating on agents used to antagonise the mechanisms associated with clotting. As we work through this section we will be referring to the latest research in the area of pharmacological management of ACS. The addendum from the 2011, NHFA relevant recommendation will guide us to the latest evidence based practice from research, for the treatment of ACS and will be a reading resource for the section. Before you begin reading about these drugs you might want to review the pathophysiology of the formation of a thrombus and the three different types of drug agents that act on the thrombotic process. You should be able to find this information in any good anatomy and physiology text and further in depth analysis in the text (Opie and Gersh, 2013) Drugs for the heart. Required reading Resource 3.5: Cannon, C.P. 2006 Evolving management of ST – segment elevation myocardial infarction: Update on recent data.The American Journal of Cardiology 98, 12A, 10Q-21Q. The article by Cannon (2006) reviews the significant advances in the management of STsegment elevation myocardial infarction (STEMI) and summarised the world wide trials which define the roles of many drug agents. For example: aspirin, unfractioned heparin (UFH), Enoxaparin – low molecular – weight heparins, the early use of glycoprotein 11b/111a inhibitors like, Tirofiban and along with (aspirin, UFH, and clopidogrel) in patients undergoing primary percutaneous coronary intervention for acute STEMI, (Cannon, 2006). Clotting is a complex cascade of reactions between different clotting factors. The three main elements enmeshed in a clot are platelets, thrombin and fibrin strands. The three main types of agents used in the arrest the thrombotic process as described by (Fox, White, Gersh and Opie, 2013): 1. platelet inhibitors – act on arterial thrombi and help prevent events such as myocardial infarction and transient ischemic attacks (TIAs) 2. anticoagulants – limit the further formation of fibrin if given accurately in the acute episode (e.g.: heparin) and when given chronically (e.g.: warfarin), helps prevents thromboembolism from dilated left atrium or from veins 3. fibrinolytic agents – are the most useful in the clinical syndromes of acute arterial thrombosis and occlusion, for example; myocardial infarction and peripheral arterial thrombosis.
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