What role do antiplatelet therapies play in the management of patients with atherosclerosis?

Antiplatelet therapies play a crucial role in the management of patients with atherosclerosis by preventing the formation of blood clots that can lead to serious cardiovascular events such as myocardial infarction (MI) and stroke NICE NG185. These therapies are particularly important in acute coronary syndromes (ACS) and for secondary prevention of thrombotic events NICE NG185.

• Acute Coronary Syndromes (ACS):
  • For patients experiencing an acute ST-segment elevation myocardial infarction (STEMI), a single loading dose of 300 mg aspirin should be offered as soon as possible, unless there is a clear allergy NICE NG185.
  • If primary percutaneous coronary intervention (PCI) is planned for STEMI, dual antiplatelet therapy (DAPT) with aspirin and either prasugrel or ticagrelor is offered NICE NG185. However, if there is an ongoing indication for oral anticoagulation, clopidogrel with aspirin is used instead NICE NG185.
  • For unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI) patients undergoing coronary angiography, prasugrel or ticagrelor, as part of DAPT with aspirin, is recommended NICE NG185. Prasugrel should only be given once coronary anatomy has been defined and PCI is intended, with consideration for bleeding risk in those aged 75 and over NICE NG185. Glycoprotein IIb/IIIa inhibitors may be used as an adjunct for complex PCI procedures in these patients NICE NG185.
  • When PCI is not indicated for unstable angina or NSTEMI, ticagrelor, as part of DAPT with aspirin, is offered unless the patient has a high bleeding risk NICE NG185. In cases of high bleeding risk where PCI is not indicated, clopidogrel with aspirin, or aspirin alone, may be considered NICE NG185.
• Secondary Prevention and Long-term Management:
  • Antiplatelet therapy is crucial for secondary stroke prevention in patients with atherosclerosis Bhatia et al. 2023Greco et al. 2023.
  • For patients who have had an MI and stopped DAPT, or had an MI more than 12 months ago and also have other clinical vascular disease, clopidogrel may be offered instead of aspirin NICE NG185.
  • When patients require ongoing oral anticoagulation, the duration and type of antiplatelet therapy (dual or single) in the 12 months after an ACS must consider bleeding risk, thromboembolic risk, cardiovascular risk, and the patient's wishes NICE NG185. Long-term triple therapy (aspirin, clopidogrel, and oral anticoagulation) significantly increases bleeding risk NICE NG185.
  • For patients on anticoagulation who have had PCI, anticoagulation and clopidogrel should be continued for up to 12 months NICE NG185. If a direct oral anticoagulant is used, the dose should be adjusted based on bleeding, thromboembolic, and cardiovascular risks NICE NG185.
  • Prasugrel or ticagrelor should not be routinely offered in combination with an anticoagulant needed for an ongoing separate indication NICE NG185.