Agresivní protidestičková léčba je základem terapie akutních koronárních syndromů. V akutní fázi je používána v podobě duální protidestičkové léčby (DAPT) s využitím vysoce účinných inhibitorů destičkového receptoru P2Y12. Studie ISAR-REACT 5 přímo srovnala ticagrelor a prasugrel jako součást dvou různých léčebných strategií. Výsledky studie jsou v rozporu s dosud zjištěnými skutečnostmi a jejich další interpretaci bude potřeba věnovat zvýšenou pozornost.

Aggressive antiplatelet therapy is the cornerstone for acute coronary syndrome treatment. Acute phase therapy is based on the dual antiplatelet treatment (DAPT) with highly effective inhibitors of the platelet receptor P2Y12. The ISAR-REACT 5 trial directly compare ticagrelor and prasugrel in two different antiplatelet strategies. The result of both efficacy and safety are contrary to current knowledge and needs to be carefully validated.

• Keywords
• studie ISAR REACT,
• MeSH
• Acute Coronary Syndrome * drug therapy   mortality   MeSH
• Purinergic P2Y Receptor Antagonists * administration & dosage   adverse effects   therapeutic use   MeSH
• Clinical Studies as Topic MeSH
• Hemorrhage MeSH
• Prasugrel Hydrochloride * administration & dosage   adverse effects   therapeutic use   MeSH
• Aged MeSH
• Ticagrelor * administration & dosage   adverse effects   therapeutic use   MeSH
• Treatment Outcome MeSH
• Check Tag
• Aged MeSH
• Publication type
• Multicenter Study MeSH
• Randomized Controlled Trial MeSH

• MeSH
• Diabetes Mellitus, Type 2 MeSH
• Glucosides administration & dosage   therapeutic use   MeSH
• Cardiovascular Diseases drug therapy   prevention & control   MeSH
• Humans MeSH
• Prasugrel Hydrochloride administration & dosage   therapeutic use   MeSH
• Randomized Controlled Trials as Topic MeSH
• Ticagrelor administration & dosage   therapeutic use   MeSH
• Valsartan administration & dosage   therapeutic use   MeSH
• Check Tag
• Humans MeSH

Nemocný po akutním koronárním syndromu je ve velmi vysokém riziku další ischemické kardiovaskulární příhody. Antitrombotická léčba, a především podávání kyseliny acetylsalicylové společně s inhibitorem P2Y12 v rámci tzv. duální antiagregace je jedním ze základních pilířů léčby po akutním koronárním syndromu. Bylo opakovaně prokázáno, že tento postup snižuje riziko další koronární příhody, ale i riziko nekoronárních kardiovaskulárních příhod, či dokonce celkové mortality. Článek přináší přehled literární evidence pro duální antiagregaci po akutním koronárním syndromu a shrnuje možnosti antiagregační léčby a současná doporučení.

The patient after acute coronary syndrome (ACS) is at a very high risk of further ischemic cardiovascular events. Antithrombotic therapy and, in particular, administration of acetylsalicylic acid together with the P2Y12 inhibitor within the so-called dual antiplatelet therapy is one of the cornerstones of treatment after ACS. This has been repeatedly shown to reduce the risk of further coronary events, but also the risk of non-coronary cardiovascular events or even overall mortality. The article presents an overview of literature for dual antiplatelet therapy after ACS and summarizes the possibilities of antiplatelet therapy and current recommendations.

• MeSH
• Acute Coronary Syndrome * drug therapy   MeSH
• Purinergic P2Y Receptor Antagonists administration & dosage   therapeutic use   MeSH
• Aspirin administration & dosage   therapeutic use   MeSH
• Platelet Aggregation Inhibitors therapeutic use   MeSH
• Clopidogrel administration & dosage   therapeutic use   MeSH
• Drug Therapy, Combination MeSH
• Humans MeSH
• Prasugrel Hydrochloride administration & dosage   therapeutic use   MeSH
• Ticagrelor administration & dosage   therapeutic use   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Review MeSH

BACKGROUND: In the ACCOAST (A Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST Elevation Myocardial Infarction) trial, the prasugrel pre-treatment strategy versus placebo was associated with excess bleeding complications and no improved ischemic outcome in non-ST-segment elevation myocardial infarction (MI). Whether patients with the longest pre-treatment duration had an ischemic benefit is unknown. OBJECTIVES: This pre-specified analysis of the ACCOAST trial aimed to assess the effect of pre-treatment duration with prasugrel (time from randomization to angiography) on outcomes. METHODS: Within the 4,033 patients randomized in the ACCOAST trial, pre-treatment duration was available in 4,001 patients (99.2%). The population of the trial was divided into quartiles of pre-treatment duration (0.1 to 2.5 h, 2.5 to 3.9 h, 3.9 to 13.6 h, and >13.6 h) with an evaluation of the primary efficacy endpoint of cardiovascular death, MI, stroke, urgent revascularization or glycoprotein IIb/IIIa inhibitor bailout use. Secondary efficacy outcomes including cardiovascular death, MI, or stroke; all-cause death; stent thrombosis and safety outcomes (all coronary artery bypass graft [CABG] or non-CABG TIMI [Thrombolysis In Myocardial Infarction] major bleeding) were also evaluated at 7 days. RESULTS: The primary efficacy outcome of cardiovascular death, MI, stroke, urgent revascularization or glycoprotein IIb/IIIa inhibitor bailout use did not differ between the quartiles of pre-treatment duration in the trial population (p = 0.17 for interaction). None of the secondary efficacy outcomes were found to be dependent on pre-treatment duration. The safety outcome of all CABG or non-CABG TIMI major bleeding did not differ between the quartiles of pre-treatment duration (p = 0.37 for interaction). CONCLUSIONS: In non-ST-segment elevation MI patients, the excess risk of bleeding and the absence of ischemic benefit were consistent across the quartiles of increasing duration of prasugrel pre-treatment. (A Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST Elevation Myocardial Infarction [ACCOAST]; NCT01015287).

• MeSH
• Time Factors MeSH
• Electrocardiography MeSH
• Non-ST Elevated Myocardial Infarction diagnosis   mortality   therapy   MeSH
• Platelet Aggregation Inhibitors administration & dosage   MeSH
• Coronary Angiography methods   MeSH
• Percutaneous Coronary Intervention methods   MeSH
• Middle Aged MeSH
• Humans MeSH
• Survival Rate trends   MeSH
• Follow-Up Studies MeSH
• Prasugrel Hydrochloride administration & dosage   MeSH
• Cause of Death trends   MeSH
• Treatment Outcome MeSH
• Dose-Response Relationship, Drug MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH
• Research Support, Non-U.S. Gov't MeSH
• Randomized Controlled Trial MeSH

• MeSH
• Acute Coronary Syndrome * drug therapy   complications   prevention & control   MeSH
• Purinergic P2Y Receptor Antagonists administration & dosage   adverse effects   therapeutic use   MeSH
• Anticoagulants administration & dosage   adverse effects   therapeutic use   MeSH
• European Union MeSH
• ST Elevation Myocardial Infarction diagnosis   drug therapy   MeSH
• Platelet Aggregation Inhibitors * administration & dosage   adverse effects   therapeutic use   MeSH
• Myocardial Ischemia diagnosis   drug therapy   prevention & control   MeSH
• Percutaneous Coronary Intervention * methods   trends   utilization   MeSH
• Humans MeSH
• Meta-Analysis as Topic MeSH
• Prasugrel Hydrochloride administration & dosage   adverse effects   therapeutic use   MeSH
• Randomized Controlled Trials as Topic MeSH
• Practice Guidelines as Topic MeSH
• Statistics as Topic MeSH
• Ticlopidine antagonists & inhibitors   adverse effects   therapeutic use   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Research Support, Non-U.S. Gov't MeSH
• Geographicals
• Czech Republic MeSH

Prudký rozvoj antitrombotické léčby významně přispěl ke zlepšení péče o pacienty s ischemickou chorobou srdeční a rozvoji intervenční kardiologie a dalších oborů zabývajících se kardiovaskulární problematikou. Práce je věnována aktuálním poznatkům v individualizaci léčby na podkladě rizikové stratifikace pacientů a léčebné strategie včetně aktuálních léčebných algoritmů pro indikaci a trvání duální protidestičkové léčby i její kombinaci s orální antikoagulační terapií.

Rapid development of antithrombotic treatment has significantly improved the quality of care of patients with ischemic heartdisease as well as contributed to the development of cardiovascular medicine and interventional cardiology, in particular. In thispaper, individualized therapy based on risk stratifications, treatment strategy, algorithms for dual antiplatelet therapy and itscombination with oral anticoagulation will be discussed.

• MeSH
• Purinergic P2Y Receptor Antagonists administration & dosage   adverse effects   therapeutic use   MeSH
• Anticoagulants administration & dosage   adverse effects   therapeutic use   MeSH
• Administration, Oral MeSH
• Aspirin administration & dosage   adverse effects   therapeutic use   MeSH
• Platelet Aggregation Inhibitors * administration & dosage   adverse effects   therapeutic use   MeSH
• Drug Therapy, Combination methods   trends   utilization   MeSH
• Percutaneous Coronary Intervention * methods   trends   utilization   MeSH
• Hemorrhage prevention & control   therapy   MeSH
• Humans MeSH
• Prasugrel Hydrochloride administration & dosage   adverse effects   therapeutic use   MeSH
• Statistics as Topic MeSH
• Drug-Eluting Stents * adverse effects   trends   utilization   MeSH
• Ticlopidine administration & dosage   adverse effects   therapeutic use   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Research Support, Non-U.S. Gov't MeSH
• Review MeSH

Multicentrická randomizovaná studie PRAGUE‑18 byla prvním přímým srovnáním účinnosti a bezpečnosti prasugrelu a tikagreloru u pacientů s akutním infarktem myokardu léčeným primární nebo neodkladnou perkutánní koronární intervencí. Studie nepotvrdila hypotézu, že jeden z léků je účinnější a/nebo bezpečnější než druhý. Diference ve výskytu sledovaných cílových ukazatelů byla minimální a klinicky irelevantní

Multicenter randomized trial PRAGUE-18 represented the first direct comparison of prasurgel versus ticagrelor effectiveness and safety in patients who suffered acute myocardial infarction treated with primary or emergent percutaneous coronary intervention. The trial did not confirm the hypothesis that one of these drugs was more effective and/or safer than the other. The differences concerning evaluated endpoints were minimal and clinically irrelevant

• Keywords
• studie PRAGUE-18, tikagrelor,
• MeSH
• Adenosine * analogs & derivatives   administration & dosage   therapeutic use   MeSH
• Myocardial Infarction * drug therapy   therapy   MeSH
• Platelet Aggregation Inhibitors administration & dosage   therapeutic use   MeSH
• Percutaneous Coronary Intervention MeSH
• Humans MeSH
• Multicenter Studies as Topic MeSH
• Prasugrel Hydrochloride * administration & dosage   therapeutic use   MeSH
• Randomized Controlled Trials as Topic MeSH
• Check Tag
• Humans MeSH

• MeSH
• Acute Coronary Syndrome * drug therapy   surgery   MeSH
• Aspirin administration & dosage   MeSH
• Platelet Aggregation Inhibitors therapeutic use   MeSH
• Myocardial Ischemia drug therapy   MeSH
• Drug Therapy, Combination MeSH
• Percutaneous Coronary Intervention methods   MeSH
• Hemorrhage chemically induced   prevention & control   MeSH
• Humans MeSH
• Perioperative Care MeSH
• Prasugrel Hydrochloride administration & dosage   MeSH
• Myocardial Revascularization methods   MeSH
• Drug Administration Schedule MeSH
• Ticlopidine administration & dosage   MeSH
• Check Tag
• Humans MeSH

BACKGROUND: No randomized head-to-head comparison of the efficacy and safety of ticagrelor and prasugrel has been published in the 7 years since the higher efficacy of these newer P2Y12 inhibitors were first demonstrated relative to clopidogrel. METHODS: This academic study was designed to compare the efficacy and safety of prasugrel and ticagrelor in acute myocardial infarction treated with primary or immediate percutaneous coronary intervention. A total of 1230 patients were randomly assigned across 14 sites to either prasugrel or ticagrelor, which was initiated before percutaneous coronary intervention. Nearly 4% were in cardiogenic shock, and 5.2% were on mechanical ventilation. The primary end point was defined as death, reinfarction, urgent target vessel revascularization, stroke, or serious bleeding requiring transfusion or prolonging hospitalization at 7 days (to reflect primarily the in-hospital phase). This analysis presents data from the first 30 days (key secondary end point). The total follow-up will be 1 year for all patients and will be completed in 2017. RESULTS: The study was prematurely terminated for futility. The occurrence of the primary end point did not differ between groups receiving prasugrel and ticagrelor (4.0% and 4.1%, respectively; odds ratio, 0.98; 95% confidence interval, 0.55-1.73; P=0.939). No significant difference was found in any of the components of the primary end point. The occurrence of key secondary end point within 30 days, composed of cardiovascular death, nonfatal myocardial infarction, or stroke, did not show any significant difference between prasugrel and ticagrelor (2.7% and 2.5%, respectively; odds ratio, 1.06; 95% confidence interval, 0.53-2.15; P=0.864). CONCLUSIONS: This head-to-head comparison of prasugrel and ticagrelor does not support the hypothesis that one is more effective or safer than the other in preventing ischemic and bleeding events in the acute phase of myocardial infarction treated with a primary percutaneous coronary intervention strategy. The observed rates of major outcomes were similar but with broad confidence intervals around the estimates. These interesting observations need to be confirmed in a larger trial. CLINICAL TRIAL REGISTRATION: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02808767.

• MeSH
• Adenosine administration & dosage   analogs & derivatives   therapeutic use   MeSH
• Adult MeSH
• Myocardial Infarction drug therapy   pathology   therapy   MeSH
• Platelet Aggregation Inhibitors administration & dosage   therapeutic use   MeSH
• Percutaneous Coronary Intervention methods   MeSH
• Middle Aged MeSH
• Humans MeSH
• Prasugrel Hydrochloride administration & dosage   therapeutic use   MeSH
• Aged MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH
• Randomized Controlled Trial MeSH

The optimal time-point of the initiation of P2Y12 antagonist therapy in patients with non-ST elevation acute coronary syndromes (NTSE-ACS) is still a matter of debate. European guidelines recommend P2Y12 as soon as possible after first medical contact. However, the only trial which compared the two strategies did not demonstrate any benefit of pre-treatment with prasugrel before angiography compared to starting therapy after angiography and just prior to percutaneous coronary intervention (PCI). This paper summarizes the results of pharmacodynamic and previous studies, and gives recommendations for the initiation of P2Y12 antagonist therapy in NSTE-ACS in different clinical situations.

• MeSH
• Acute Coronary Syndrome drug therapy   MeSH
• Purinergic P2Y Receptor Antagonists administration & dosage   therapeutic use   MeSH
• Administration, Oral MeSH
• Clinical Trials as Topic MeSH
• Coronary Angiography MeSH
• Percutaneous Coronary Intervention MeSH
• Humans MeSH
• Prasugrel Hydrochloride administration & dosage   therapeutic use   MeSH
• Practice Guidelines as Topic MeSH
• Treatment Outcome MeSH
• Check Tag
• Humans MeSH
• Male MeSH
• Female MeSH
• Publication type
• Journal Article MeSH