Ticagrelor Along With Clopidogrel Now Recommended For Unstable Angina

 Recommendatuions For Unstable Angina

According the new guidelines issued by the American Heart Association  (AHA) and the American College of Cardiology (ACTA) Foundation, an antiplatelet agent, ticagrelor (Brilinta) , should be administered along with clopidogrel or prasugrel. So far ticagrelor was recommended to moderate to high risk patients for ischemic events, even if patients were previously treated with clopidogrel ( which would be stopped at the beginning of ticagrelor).

The new changes that have focused on the treatment of unstable angina and NSTEMI (non ST myocardial infaction) were published in the Journal of the American Heart Association and the Journal of the American College of Cardiology. According to the guidelines, the drug of first choice given to patients with unstable angina (or stable) is aspirin. If aspirin is not tolerated,  prasugrel is recommended for all patients undergoing coronary interventions . If patients receive medical therapy or undergoing invasive surgery, then they can receive either ticagrelor (Brilinta) or clopidogrel. Also an invasive intervention require both aspirin and other antiplatelet agent.

Ticagrelor

Regarding duration of therapy, aspirin should be taken for life and clopidogrel or ticagrelor should be taken 12 months. Hani Jneid, M.D., lead author of the update and an assistant professor of medicine and director of interventional cardiology research at Baylor College of Medicine, and an interventional cardiologist at the Michael E. DeBakey VA Medical Center in Houston, said that these updates in guides are useful for clinicians to make treatment as appropriate and as aggressive to patients in order to improve quality of life and  survival.

Unstable angina and NSTEMI are part of what is called acute coronary syndrome, a condition that is due to decreased oxygen supply to the heart. Diagnosis is based on electrocardiogram and troponin measurements, which are increased in NSTEMI. Stable angina and unstable angina has different features . In unstable angina, unlike stable angina, chest pain may occur at rest, lasts longer than 15-20 minutes, and is more intense. Risk stratification is based on several parameters, such as recurrent chest pain, ECG changes, troponin, age, other diseases (renal failure, diabetes). Treatment that is given to patients with acute coronary syndromes consists of anti-ischemic drugs, anticoagulants, antiplatelet and revascularization. Aspirin, clopidogrel, prasugrel and ticagrelor are drugs with antiplatelet effects. Unlike the last three, aspirin inhibits cyclooxygenase, an enzyme that helps to form thromboxane A2.

Clopidogrel, prasugrel and ticagrelor are inhibitors of ADP receptor (P2Y12), that is inhibits a process that is involved in platelet aggregation. All these drugs are important in the treatment of cardiac patients because they  prevent thrombus formation that can lead to heart attack. Ticagrelor, unlike clopidogrel and prasugrel, is reversible, and active since the time of administration. It takes effect in 30 minutes, duration of effect is 3-4 days and should be removed 5 days before major surgery.