Antiagregantes plaquetarios: ¿En dónde se encuentran las diferencias?

Dr. José Miguel Chaverri Fernández
Profesor Asociado del Departamento de Farmacología, Toxicología y Farmacodependencia de la Facultad de Farmacia de la Universidad de Costa Rica y Farmacéutico Clínico, Hospital Clínica Bíblica.
Miembro del Colegio de Farmacéuticos de Costa Rica.
Costa Rica.

Dr. José Pablo Díaz Madriz
Farmacéutico Clínico del Hospital Clínica Bíblica.
Miembro del Colegio de Farmacéuticos de Costa Rica.
Costa Rica.

Dra. Eugenia Cordero García
Departamento de Farmacología, Toxicología y Farmacodependencia de la Facultad de Farmacia de la Universidad de Costa Rica.
Miembro del Colegio de Farmacéuticos de Costa Rica.
Costa Rica.

José Pablo Ramírez
Estudiante de Internado en Farmacia, Universidad de Costa Rica.
Costa Rica.

Karina Villalta
Estudiante de Internado en Farmacia, Universidad de Ciencias Médicas, Costa Rica.
Costa Rica.

Dr. Esteban Zavaleta Monestel
Farmacéutico y Director de Farmacia Hospital Clínica Bíblica.
Miembro del Colegio de Farmacéuticos de Costa Rica.
Costa Rica.

Resumen

Las guías de tratamiento apoyan el uso de antiagregantes plaquetarios como parte de la prevención y manejo de la enfermedad arterial coronaria, debido a la existencia de evidencia clínica que respalda el beneficio en la reducción de la morbimortalidad cardiovascular en pacientes post infartados que utilizan este tipo de tratamientos. Sin embargo, existe aún controversia sobre los parámetros requeridos para la elección e individualización de la terapia antiagregante plaquetaria en prevención secundaria.

La presente revisión tiene como objetivo suministrar una guía al lector que le facilite la elección de la mejor estrategia antiagregante plaquetaria según las características individuales del paciente, la clínica y el medicamento, a fin de hacer una comparación aproximada entre los nuevos productos, debido a la escasa existencia de estudios clínicos.

---

Palabras claves

Antiagregantes plaquetarios, síndrome coronario agudo, farmacoterapia.

Abstract

Treatment guidelines support the use of antiplatelet agents as part of the prevention and management of coronary artery disease, due to the existence of clinical evidence supporting the benefit in reducing cardiovascular morbidity and mortality in post heart attack patients who use this type of treatments. However, there is still controversy over the parameters required for election and individualization of antiplatelet platelet therapy in secondary prevention.

This review aims to provide guidance to the reader that facilitates the choice of the best antiplatelet strategy according to individual patient, clinical and medicine characteristics, providing a guide to provide an approximate comparison due to the lack of existence of studies clinical comparing new products with each other.

---

Keywords

Antiplatelets, coronary acute syndrome, pharmacotherapy.

Bibliografía

---

Antithrombotic Trialists' (ATT) Collaboration (2009) Aspirin in the primary And secondary prevention of vascular disease: collaborative Meta-analysis of individual participant data from randomized trials. Lancet, 373 (9678): 1849-60.

Bartolucci, A.; Tendera, M. & Howard, G. (2011) Meta-analysis of multiple primary prevention trials of cardiovascular events using aspirin. The American journal of cardiology, 107(12): 1796-1801.

Bonaca, M.; Bhatt, D.; Cohen, M.; Steg, P. et al. (2015) Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med, 372(19): 1791-1800.

Brunton, L.; Chabner, B. & Knollmann, B. (7 de junio de 2016) Blood Coagulation and Anticoagulant, Fibrinolytic, and Antiplatelet Drugs. En: Goodman & Gilman's: The Pharmacological Basis of Therapeutics. Recuperado de http://accesspharmacy.mhmedical.com.ezproxy.sibdi.ucr.ac.cr:2048/content.aspx

Califf, R. et al. (2012) The future of cardiovascular clinical research. JAMA, 308:1747-1748.

CAPRIE Steering Committee (1996) A randomized, blinded, trial of clopidogrel versus aspirin in patients at risk of ischemic events (CAPRIE). Lancet, 348: 1329–1339.

Cayla, G.; Cuisset, T.; Silvain, J. et al.(2016) Platelet function monitoring to adjust antiplatelet therapy in elderly patients stented for an acute coronary syndrome (ANTARCTIC): An open-label, blinded-endpoint, randomized controlled superiority trial.  Lancet. Doi:10.1016/S0140-6736 (16)31323-X

Collet, J.; Cuisset, T., Rangé, G, et al. (2012) Bedside monitoring to adjust antiplatelet therapy for coronary stenting. N Engl J Med., 367:2100-2109.

Eisenstein, E.; Anstrom, K.; Kong, D.; Shaw, L. et al. (2011) Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA, 297(2): 159-68.

Ho, P.; Maddox, T.; Wang, L.; Fihn, S. et al.(2009) Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome. JAMA, 301(9): 937-944.

ISIS-2 (Second International Study of Infarct Survival) Collaborative Group (1988) Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected actua myocardial infarction ISIS-2. Lancet, 2: 349-360.

James, S.; Akerblom, A.; Cannon, C.(2009) Comparison of ticagrelor, the first reversible oral P2Y12 receptor antagonist, with clopidogrel in patients with acute coronary syndromes: rationale, design, and baseline characteristics of the Platelet inhibition and patient Outcomes (PLATO) trial. Am Heart J., 157: 599-605.

James, S.; Storey, R.; Khurmi, N.; Husted, S. et al.(2012) Ticagrelor versus clopidogrel in patients with acute coronary syndromes and a history of stroke or transient ischemic attack.Circulation.CIRCULATIONAHA,111.14.

Johnston, S.; Amarenco, P.; Albers, G. W.; Denison, H., et al. (7 de junio de 2016) Ticagrelor versus aspirin in acute stroke or transient ischemic attack. Recuperado de: http://www.nejm.org/doi/full/10.1056/NEJMoa1603060

Kaiser, C.; Galatius, S.; Erne, P. et al. (2010) BASKET–PROVE Study Group. Drug-eluting versus bare-metal stents in large coronary arteries. N Engl J Med., 363:2310-2319.

Kirtane, A. & Stone, G. (2011) How to minimize stent thrombosis. Circulation, 124(11): 1283-1287.

Lars, W.; Baker, R.; Andrzej, B.; Cannon, C. et al. (2009) Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med., 361: 1045-1057.

Mehran, R.; Baber, U.; Steg, P. et al. (2013) Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet; 382:1714-1722.

Mak, K.; Bhatt, D.; Shao, M.; Hankey, G. et al.(2009) Ethnic variation in adverse cardiovascular outcomes and bleeding complications in the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) study. American Heart Journal, 157(4): 658-665.

Mauri, L.; Kereiakes, D.; Yeh, R.; Driscoll-Shempp, P. et al.(2014) Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med., 371(23): 2155-66.

Mehta, S; Yusuf, S.; Peters, R.; Bertrand, M. et al. (2001) Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI- CURE study. Lancet, 358: 527-533.

Ministerio de Salud. Dirección de la Vigilancia de Salud.(2014) Análisis de situación de salud Costa Rica. Recuperado de https://www.ministeriodesalud.go.cr/index.php/vigilancia-de-la-salud/analisis-de-situacion-de-salud/2618-analisis-de-situacion-de-salud-en-costa-rica/file

Morice, M.; Serruys, P.; Sousa, J.; Fajadet, J. et al. (2002) A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med., 346(23): 1773-1780.

Mozaffarian, D.; Benjamin, E.; Go, A.; Arnett, D.; Blaha, M.; Cushman, M. et al. (2015) Heart disease and stroke statistics— 2015 update: a report from the American Heart Association. Circulation, 131: 29-322

Motovska, Z.; Hlinomaz, O.; Miklik, R. et al. (2012) PRAGUE-18: Prasugrel, Ticagrelor Equal in STEMI, but Questions Remain. Medscape.

Moussa, I.; Klein, L.; Shah, B.; Mehran, R. et al. (2012) Consideration of a new definition of clinically relevant myocardial infarction after coronary revascularization: an expert consensus document from the Society for Cardiovascular Angiography and  Interventions (SCAI). JAC, 62(17): 1563-1570.

O’Gara, P.; Kushner, F.; Ascheim, D. et al. (2013) ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology Foundation/American. Journal of the American College of Cardiology, 61(4): 485-510.

OMS. Evite los infartos de miocardio y los accidentes cerebrovasculares (2016), Recuperado de http://apps.who.int/iris/bitstream/10665/43402/1/9243546724_spa.pdf

Roe, M.; Armstrong, P.; Fox, K.; White, H. et al. (2012) Prasugrel versus clopidogrel for acute coronary syndromes without revascularization. N Engl J Med., 367(14): 1297-1309

Roffi. M.; Patrono, C.; Collet, J. et al. (2016) 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation. Eur Heart J., 37: 267.

Yusuf, S.; Zhao, F.; Mehta, S.; Chrolavicius, S. et al. (2001) Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST segment elevation. N Engl J Med., 345: 494-502.

.Wiviott, S.; Antman, E. & Gibson, C. (2006) Evaluation of prasugrel compared with clopidogrel in patients with acute coronary syndromes: design and rationale for the Trial to assess Improvement in Therapeutic Outcomes by optimizing platelet Inhibition with prasugrel Thrombolysis in Myocardial infarction. Am Heart J., 152: 627-35.

Fuentes de Apoyo:

No hubo aporte económico de ningún tipo para la realización de esta revisión de tema.

Conflictos de Interés:

Los autores declaran que no existe ningún tipo de conflicto de interés que pudiese haber afectado la realización de dicha revisión de tema.