[Platelet antiaggregation treatment in the aftermath of GUSTO IV, TARGET, TACTICS, and CURE trials]

Abstract

Various clinical studies have shown that the risk associated with acute coronary syndrome can be reduced by pharmacological treatment with platelet glycoprotein IIb-IIIa receptor inhibitors. The treatment with these drugs is beneficial in conjunction with conventional medical treatment, during angioplasty and in patients undergoing aortocoronary bypass, as indicated by the results of the CAPTURE, PRISM, and PURSUIT studies. However, shortly after the European Society of Cardiology recommended systematic use of glycoprotein IIb-IIIa inhibitors in the management of high-risk patients, the report of negative results in the GUSTO IV and TARGET trials caused this position to be reconsidered. The need for studies to better characterize the mechanism of action of these antithrombotic agents is evident. Studies in vitro have demonstrated that prolonged treatment with these drugs can cause patients to remain outside the therapeutic range by causing platelet receptors to change configuration and have more affinity for fibrinogen. In view of these findings, the results of the GUSTO IV and TARGET studies, far from demonstrating the ineffectiveness of the antiplatelet aggregation agents, could be interpreted as a failure in the design of the therapeutic strategy. On the other hand, the results of the CURE study provide new evidence of the benefits of the use of clopidogrel in patients with acute coronary syndrome undergoing medical or revascularization treatment (PCI-CURE group). The debate about the usefulness of platelet glycoprotein IIb-IIIa inhibitors, alone or in combination with clopidogrel in certain circumstances remains open. The evidence available to date is inconclusive and the guidelines for the management of patients with acute coronary syndrome should be updated.