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All the data available so far is not without deficiencies. Most of
the trials performed have included the entire spectrum of acute coronary
syndromes without making distinction between the Non ST elevation MI, ST
elevation MI and acute coronary syndromes without any rise in cardiac
enzymes. It is very well known that the pathophysiologic basis of
diferrent acute coronary syndromes is different. The clinical outcomes of
acute coronary syndromes secondary to plaque erosions are different to
that of plaque ruptures. The clinical outcomes of PCI in long segment
disease , proximal disease, left main stem disease , ulcerated plaque
disease or disease with multiple lesions would be different to that of
disease with a single type A lesion. At our institution where annually
more than 600 PCIs are performed we use clopidogrel loading dose of 300 mg
and continue DAT for more than a year.
The future studies we feel will need to take following factors into
consideration as these factors may determine the type, dosage and
duration of antiplatelet therapy atleast in clinical settings:
1) The pathophysiological basis of acute coronary syndrome which may be
determined with IVUS as either plaque erosion or plaque rupture. As plaque
ruptures tend to cause larger infarcts with poorer clinical outcome than
plaque erosions alone.
2) The degree of thrombus burden and intensity of thrombus propagation
evident at the time of PCI especially primary PCI . Whether mechanical
thrombus aspiration was required or not ?
3) The types of lesions requiring PCI. Proximal lesions v/s more distal
lesions. Diameter of the vessel stented and complexity of the lesion (Type
4) The possibility of hyporesponsiveness to antiplatelet therapy and the
presence of antiplatelet resistance as clinical measurement of
antiplatelet resistance may become a reality very soon.
We complement the authors of this update once again for touching upon
almost all relevant concerns in interventional cardiac practice.
1.Abhiram Prasad and David R Holmes. Update on dual antiplatelet therapy for percutaneous coronary intervention. Heart, Jun 2009; 95: 861 - 865.
2. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. 2001 Aug 16; 345(7):494-502
3.Prasugrel versus clopidogrel in patients with acute coronary syndrome. NEJM - 2007 Nov 15 ; 357 : 2001-2015
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