The Role(s) of Antiplatelet Therapy in Atherothrombosis
The Role(s) of Antiplatelet Therapy in Atherothrombosis
The excitement about drug-eluting stents has dominated the "news" at recent cardiology congresses, and deservedly so, because without doubt they will prove to be one of the major advances in cardiovascular medicine in this decade. However, it is important at the beginning of this drug-eluting stent era to realize that there are many other critical components to interventional cardiology and the practice of cardiovascular medicine.
On the one hand, it has been shown conclusively that in patients presenting with acute coronary syndromes (ACS), the preferred treatment approach is an invasive strategy. Especially in patients with intermediate or high-risk ACS, the results of several well-conducted clinical trials have shown conclusively that an invasive strategy has mortality and morbidity benefits over an optimally configured conservative strategy.
On the other hand, while we can be certain that interventional therapies are important in the management of ACS, it remains important to realize that ACS is only the tip of what can be called the atherothrombotic iceberg (Figure 1). Thus, beyond identifying high-risk ACS patients, we need to diagnose the other examples of plaque rupture presentations, such as patients with ST-segment elevation myocardial infarction (MI) as well as many cases of transient ischemic attack and ischemic stroke. It is equally important to identify and treat these patients, and increasingly this will involve endovascular techniques.
(Enlarge Image)
Atherosclerotic iceberg.
The underlying and under-recognized problem that it is critical to realize is that all of these patients have subclinical risks. These subclinical risks fall, I believe, into 3 principal categories:
The excitement about drug-eluting stents has dominated the "news" at recent cardiology congresses, and deservedly so, because without doubt they will prove to be one of the major advances in cardiovascular medicine in this decade. However, it is important at the beginning of this drug-eluting stent era to realize that there are many other critical components to interventional cardiology and the practice of cardiovascular medicine.
On the one hand, it has been shown conclusively that in patients presenting with acute coronary syndromes (ACS), the preferred treatment approach is an invasive strategy. Especially in patients with intermediate or high-risk ACS, the results of several well-conducted clinical trials have shown conclusively that an invasive strategy has mortality and morbidity benefits over an optimally configured conservative strategy.
On the other hand, while we can be certain that interventional therapies are important in the management of ACS, it remains important to realize that ACS is only the tip of what can be called the atherothrombotic iceberg (Figure 1). Thus, beyond identifying high-risk ACS patients, we need to diagnose the other examples of plaque rupture presentations, such as patients with ST-segment elevation myocardial infarction (MI) as well as many cases of transient ischemic attack and ischemic stroke. It is equally important to identify and treat these patients, and increasingly this will involve endovascular techniques.
(Enlarge Image)
Atherosclerotic iceberg.
The underlying and under-recognized problem that it is critical to realize is that all of these patients have subclinical risks. These subclinical risks fall, I believe, into 3 principal categories:
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