Abstract

Aggressive Approach in ACS : From Acute to Secondary Prevention

dr. Dendi Puji Wahyudi, Sp.JP

Acute thrombosis is induced by a ruptured or eroded atherosclerotic coronary plaque, with or

without concomitant vasoconstriction, causing a sudden and critical reduction in blood flow. Acute
coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart and
include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable
angina. Early diagnosis and early treatment is critical for ACS management. Inhibition of platelet
function with dual antiplatelet therapy (DAPT) is the basis of treatment of acute coronary syndrome
(ACS). On the other hand, preventing ischemic recurrence with antiplatelet is clearly associated with
an increased risk of bleeding. Achieving balance between protection of future ischemic event and
bleeding complication is a main goal on Acute Coronary Syndrome (ACS) Management. Although
choosing the proper medication for ACS patients is often problematic due to possible share of
ischemic vs bleeding risk. Recent guideline along with previous studies tell us how important to
personalized treatment of each patient, especially when it comes to choose the right antiplatelet for
our ACS patients. Nowadays, widely use of potent antithrombotic and increase on application of
invasive strategy to treat Acute Coronary Syndrome (ACS), have the risk of recurrent ischemic events
reduce. Since 2020 ESC Guidelines for ACS without ST-segment elevation give prasugrel and
ticagrelor a class I recommendation, whereas clopidogrel is recommended for patients who cannot
use or tolerate prasugrel or ticagrelor.

In patients who have acute coronary syndromes with or without ST-segment elevation, clinical
practice guidelines recommend dual antiplatelet treatment with aspirin and P2Y12 inhibitor
(Ticagrelor, Prasugrel or Clopidogrel). The efficacy of clopidogrel is hampered by the slow and
variable transformation of the prodrug to the active metabolite, modest and variable platelet
inhibition, an increased risk of bleeding and an increased risk of stent thrombosis and myocardial
infarction in patients with a poor response. Ticagrelor, a reversible and direct-acting oral antagonist
of the adenosine diphosphate receptor P2Y12, provides faster, greater, and more consistent P2Y12
inhibition than clopidogrel. In patients with ACS, aspirin therapy is conventionally given as soon as
possible. If P2Y12 inhibitor treatment is not initiated before coronary angiography, it is typically
administered in the catheterization laboratory at the time of PCI. For P2Y12 inhibitors, treatment
options that are orally administered include clopidogrel, prasugrel and ticagrelor. Ticagrelor has a
more rapid and consistent onset of action and offset compared with clopidogrel (41% IPA Ticagrelor
vs 8% IPA Clopidogrel at 30 minutes). In PLATO study, Ticagrelor reduces the primary end point — a
composite of death from vascular causes, myocardial infarction, or stroke significantly compare to
clopidogrel (9,8% VS 11%, hazard ratio, 0.84; 95% confidence interval [CI], 0.77 to 0.92; P<0.001).
Ticagrelor also significantly reduced death from vascular causes compare clopidogrel (4.0%, vs. 5.1%;
P<0.001). No significant difference in the rates of major bleeding was found between the ticagrelor
and clopidogrel groups (11.6% and 11.2%, respectively; P = 0.43), but ticagrelor was associated with
a higher rate of major bleeding not related to coronary-artery bypass grafting (4.5% vs. 3.8%, P =
0.03), including more instances of fatal intracranial bleeding and fewer of fatal bleeding of other
types.

Keywords : ACS, STEMI, NSTEMI, Ticagrelor,P2Y12