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                     In medical practice, cases in which patients with acute coronary syndrome (ACS) and received a combination of acetylsalicylic acid (ASA) with prasugrel or ticagrelor are often used, a combination of ASA with clopidogrel is started. This transition from more active platelet-derived P2Y12 blockers to less active clopidogrel has been termed "de-escalation."

                     The possibility of "de-escalation" is considered in documents prepared by various expert groups. Among them, an updated version of the recommendations of the European Society of Cardiology and the European Association of Cardio Thoracic Surgeons for double antiplatelet therapy for coronary heart disease, where a similar transition is proposed to be discussed with side effects or intolerance of prasugrel / ticagrelor. There is also an agreement of experts from Europe and the USA, in which practical approaches to the replacement of the P2Y12 blocker of the platelet receptor are analyzed in detail. However, it should be borne in mind that these proposals are basically based on common sense and representations of the pharmacological properties of various P2Y12 receptor blockers of the platelet, while the evidence base for "de-escalation" is small.

                     Thus, in a recently published prospective clinical study TOPIC, most closely approximated to everyday medical practice, the transition from prasugrel or ticagrelor to clopidogrel within a month after coronary stenting in patients with acute coronary syndrome was not accompanied by an increase in the incidence of ischemic complications and gave a gain in safety decrease in the frequency of clinically significant bleeding). However, the limitations of this clinical trial (a small number of patients, the open nature of the study) do not give grounds for changing existing approaches to the choice of the composition of double antiplatelet therapy after ACS. In addition, TOPIC studies contradict the results of large controlled clinical trials of TRITON-TIMI 38 and PLATO, which demonstrated a positive effect with prolonged use of a combination of ASA with prasugrel or ticagrelor in comparison with its combination with clopidogrel. Obviously, before the resolution of these contradictions and the emergence of new facts, it is premature to consider the expediency of widespread use of "de-escalation". However, if a particular patient is talking about early termination of double antiplatelet therapy after ACS, switching from prasugrel or ticagrelor to clopidogrel is a more attractive alternative.

    Literature

    1. Valgimigli M., Bueno H.., Byrne R.A., et al. ESC Scientific Document Group; ESC Committee for Practice Guidelines (CPG); ESC National Cardiac Societies. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39: 213-260.
    2. Angiolillo D.J., Rollini F., Storey R.F., et al. International Expert Consensus on Switching Platelet P2Y12 Receptor–Inhibiting Therapies. Circulation 2017; 136: 1955-1975.
    3. Cuisset T., Deharo P., Quilici J., et al. Benefit of switching dual antiplatelet therapy after acute coronary syndrome: the TOPIC (timing of platelet inhibition after acute coronary syndrome) randomized study. Eur Heart J 2017; 38: 3070-3070.
    4. Morrow D.A., Wiviott S.D., White H.D., et al. Effect of the Novel Thienopyridine Prasugrel Compared With Clopidogrel on Spontaneous and Procedural Myocardial Infarction in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis in Myocardial Infarction 38. An Application of the Classification System From the Universal Definition of Myocardial Infarction. Circulation 2009; 119: 2758-2764.
    5. Steg P.G., James S., Harrington R.A., et al.; for the PLATO Study Group. Ticagrelor Versus Clopidogrel in Patients With ST-Elevation Acute Coronary Syndromes Intended for Reperfusion With Primary Percutaneous Coronary Intervention. A Platelet Inhibition and Patient Outcomes (PLATO) Trial Subgroup Analysis. Circulation 2010; 122: 2131-2141.

     

    Igor S. Yavelov, MD, PhD

    Moscow





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