Arq. Bras. Cardiol. 2021; 116(2): 236-237
Is There a Second Wind for Glycoprotein IIb/IIIa Inhibitors in Elderly Diabetic Females with ST-Elevation Myocardial Infarction, or are We on Thin Ice?
This Short Editorial is referred by the Research article "Therapeutic Effects of Triple Antiplatelet Therapy in Elderly Female Patients with Diabetes and Acute Myocardial Infarction".
The standard of care in patients undergoing primary percutaneous coronary intervention (PCI) is double antiplatelet therapy (DAPT), with a combination of aspirin and a P2Y12 inhibitor. Prasugrel and ticagrelor are the preferred P2Y12 inhibitors because they have a more rapid onset of action, greater potency, and are superior to clopidogrel in terms of clinical outcomes. They should be maintained over 12 months unless there are contraindications, such as excessive risk of bleeding. The choice of treatment should be a balanced decision, considering the ischemic and bleeding risks. Most of the trials evaluating glycoprotein (Gp) IIb/IIIa inhibitors in ST-elevation myocardial infarction (STEMI) patients treated with primary PCI pre-date the era of routine oral DAPT pre-treatment, particularly in the setting of potent oral platelet inhibitors. At that time, they demonstrated a reduction in the incidence of ischemic events, but at the expense of a consistent increase in major bleeding. Presently, there is no compelling evidence for an additional benefit of the routine use of a Gp IIb/IIIa strategy in primary PCI patients that receive DAPT treatment, particularly with ticagrelor. The use of Gp IIb/IIIa inhibitors should be considered for bailout therapy in the event of angiographic evidence of a large thrombus, slow- or no-reflow, and other thrombotic complications, although this strategy has not been addressed in randomized controlled trials. Also, intracoronary administration is not superior to its intravenous use.
Elderly patients are at high-risk of bleeding and other complications from acute therapies, not only because of their age, but because they have more often renal dysfunction and more co-morbidities. Diabetes is also a frequent comorbidity in STEMI patients. Diabetic patients have more diffuse atherosclerotic disease and are at higher risk of death and complications, including repeated revascularization after PCI. In fact, diabetic patients who have suffered a myocardial infarction have a worse prognosis, and the presence of diabetes amplifies the risk of any cardiovascular event, as shown in many previous studies of acute coronary syndrome treatment.,, However, in the current context of the use of oral P2Y12 inhibitors, there is no indication that antithrombotic pharmacotherapy should differ between diabetics and patients without diabetes undergoing revascularization.,
[…]
1,318
