Antiplatelet Therapy for Improving Post-PCI Outcomes: Interpreting Current Treatment Guidelines for Optimal Management of the Post-ACS Patient

Dual antiplatelet therapy with a thienopyridine in combination with aspirin for 1 to 6 months after stenting has been recommended by the manufacturers to reduce ischemic cardiovascular events and thrombosis after coronary stenting, whereas the current leading guidelines recommend dual antiplatelet therapy for 12 months following percutaneous coronary intervention in all patients not at high risk of bleeding. Despite the established benefits of dual antiplatelet therapy in acute coronary syndrome (ACS) patients, there are concerns regarding the risk of major bleeding. The risks, benefits, and complexity identified in these interventional trials are communicated in this article to enable well-informed therapeutic decisions. Thienopyridine nonresponsiveness and variability of response are emerging as significant concerns in ACS patients that may lead to poor long-term cardiovascular outcomes. Current research on thienopyridine responsiveness and evidence-based mechanisms for overcoming thienopyridine nonresponsiveness are discussed. In addition, adherence to dual antiplatelet therapy is critical but difficult to achieve, and a considerable proportion of patients (1 of 7) discontinue therapy before 30 days of drug-eluting stent implantation. It has been established that premature discontinuation of thienopyridine therapy is associated with a marked increase in the risk of stent thrombosis (and consequently myocardial infarction and/or death) and is the leading independent predictor of stent thrombosis in multivariate analyses. The factors related to premature cessation of thienopyridine therapy are listed with recommendations for minimizing the complications arising as a result of premature discontinuation.