Antiplatelet therapy in patients with coronary artery disease

Treatment with aspirin has been a cornerstone of acute therapy and of secondary prevention for patients with active coronary artery disease, and in particular those with acute myocardial infarction, acute coronary syndromes, and those undergoing either percutaneous or surgical revascularization. Studies within the past decade have highlighted the added benefit of treatment with antagonists of P2Y₁₂ among those with acute coronary syndromes and those undergoing percutaneous revascularization. The optimal duration of treatment appears to be at least 15 months after the onset of the acute coronary syndrome or 30 months for patients who undergo intracoronary implantation of a drug eluting stent, however studies with newer generation stents in selected patients have indicated that shorter durations may well be acceptable. For patients who also have a need for an oral anticoagulant, particularly those with atrial fibrillation or with mechanical prosthetic heart valves, the anti-platelet drug regimen is much less clear. Clinical trials of new regimens in this situation continue to evolve and have indicated that prolonged duration of a triple drug regimen (oral anticoagulant, aspirin, and a P2Y₁₂ antagonist) is associated with an increased risk of hemorrhage, and that a regimen that excludes aspirin may be acceptable.