New guide to add Ticagrelor to treat UA/NSTEMI

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) jointly publish a new clinical guideline for the treatment of unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and recommend the antiplatelet drug ticagrelor As an alternative to prasugrel and clopidogrel.

The latest guideline issued this time replaced the 2011 version of the guideline, which was not included in ticagrelor.

The current European UA/NSTEMI guidelines explicitly recommend that ticagrelor is preferred, followed by prasugrel [used for patients prior to percutaneous coronary intervention (PCI)] and clopidogrel (used for ticagrelor and pharmacological failure) Lagres these patients with new drugs).

However, the main authors of ACCF/AHA guidelines are Houston Baylor College of Medicine and Michael E. Dr. Hani Jneid of DeBakey VA Medical Center emphasized that they do not believe that one of the three recommended P2Y12 receptor inhibitors is better for UA/NSTEMI. Dr. Jneid and his colleagues stated that although these drugs are used on the same basis in the ACCF/AHA guidelines, they are not interchangeable and should be used clinically in strict accordance with the usage in the trial.

Cardiologist Eric M of the University of Michigan, Ann Arbor. In an interview, Bates pointed out that both ticagrelor and prasugrel are more potent than clopidogrel, and both should be avoided in patients with transient ischemic attack or stroke. For patients over 75 years of age, clopidogrel with a more moderate effect is generally used. If you use more potent antiplatelet therapy, the cost is higher.

There are some differences between the latest guidelines and previous guidelines. In previous guidelines, AHA/ACCF recommended that all patients with UA/NSTEMI apply aspirin immediately after hospitalization and continue to use it until they cannot tolerate it. Patients undergoing elective invasive surgery should receive preoperative double therapy with aspirin plus clopidogrel, ticagrelor, eptifibatide, or tirofiban; prasugrel can be used after PCI. Both ticagrelor and clopidogrel are suitable for patients on purely drug therapy and those on PCI. Patients who cannot tolerate aspirin can receive clopidogrel, prasugrel (for PCI patients), or ticagrelor monotherapy.

The new guidelines recommend that patients undergoing drug therapy continue aspirin application immediately after admission and clopidogrel or ticagrelor as soon as possible; clopidogrel or ticagrelor may be used continuously for up to 12 months, while aspirin should be applied continuously indefinitely. The 2011 guidelines recommend antiplatelet therapy for at least 1 year. Another change relates to the use of patients with warfarin: the new guidelines consider oral anticoagulant therapy as a lower INR (eg, 2.0 to 25), probably for UA/NSTEMI patients with aspirin and P2Y12 inhibitors. It is reasonable.

Dr. Elliott Antman of the Brigham and Women's Hospital and Harvard Medical School appreciated the detailed introduction of the guidelines for the administration of anticoagulation and antiplatelet therapy and considered that the editorial board would not say that one drug is superior to another. The drug practice is quite reasonable because prasugrel and ticagrelor are only compared with clopidogrel, and there is no comparison between the first two groups and the study population is different. However, Dr. Antman quoted an accompanying editorial in May 2010 and pointed out that there is no evidence that the use of prasugrel and ticagrelor as new drugs for patients with previous stroke or transient ischemic attack is safe (Circulation 2012) ;125:2821-23). He also reminded clinicians that the secondary prevention guidelines for stroke management do not recommend the use of aspirin and clopidogrel unless there is a clear cardiovascular indication.

Dr. Jneid stated that there are no economic conflicts of interest related to this guideline, but 7 of the 15 editorial board members are associated with AstraZeneca, Eli Lilly and Bristol-Myers Squibb/Sanofi (Ticagre and Pu, respectively). There is a link between Lagrex and the manufacturer of clopidogrel. Dr. Bates admitted to serving as a consultant for the three companies and Dr. Antman stated that he has received support from these companies.