A Rational Approach to a De-Escalation of Double Antithrombotic Therapy: The Possibilities of Clopidogrel

Abstract

In the review based on existing clinical recommendations and guidelines of the European cardiology society and results of clinical and register trials difficult questions about a antithrombotic therapy in the patients with an acute coronary syndrome and percutaneous coronary interventions were discussed. The perspective strategy of risk management on ischemic and hemorrhagic events were described. Need of the maximum personification of purpose of double antithrombotic therapy at patients with an acute coronary syndrome or after carrying out transdermal coronary interventions is updated. Real requirement on constant assessment of balance in risks of ischemic and hemorrhagic events in this group of patients were defined. The perspective strategy of risk management in ischemic and hemorrhagic events from a position of results of relevant clinical trials were described. Results of clinical trials (TOPIC, TROPICAL-ACS) about transfer the ACS patients from “new” desaggregants on clopidogrel were presented (De-Escalation approach). Examples of the clinical situations suitable for realization of such approach were reviewed. The prospects of use of De-Escalation approach are designated and positions of a clopidogrel and, in particular, the original drug Plavix were provided. At the same time, appointment in patients with ACS within 12 months of double antiaggregant therapy is the proved option of treatment allowing to improve the prognisis. However, in some cases there is a reasonable requirement of the transfer of the patient from the “new” antiaggregants (ticagrelor or prasugrel) to clopidogrel (“de-escalation”). It needs to perfome according to the available evidence base recommendations and it is strict according to clinical indications. In particular, patients can have a perspective de-escalation with high risk of bleedings or with already developed bleeding; in patients with the forced refusal of reception of “new” antiaggregants owing to development of side effects / intolerance / allergic reactions; in the presence of indications for life long intake of anticoagulants in case of the need for purpose of double or triple antithrombotic therapy; in patients with ACS with low risk.