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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses strategies for long-term antithrombotic therapy, ways to balance the risks and benefits of antithrombotic therapy, as well as gives an overview of evidence supporting the use of long-term antithrombotic therapy after acute coronary syndrome, and suggests strategies for balancing the benefits and risks of long-term antithrombotic therapy for patients with NSTEMI or STEMI.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ethrombotic disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emyocardial infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EStrategies for Long-Term Antithrombotic Therapy\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EAspirin therapy has consistently been shown to reduce the rate of cardiovascular events in secondary prevention following a cardiovascular event. However, aspirin alone is not sufficient to prevent ischemic events in patients at high risk, said Freek Verheugt, MD, PhD, Radboud University Nijmegen, The Netherlands. Prof. Verheugt provided an overview of evidence supporting the use of long-term antithrombotic therapy after acute coronary syndrome (ACS).\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EDual antiplatelet therapy with clopidogrel and aspirin reduces ischemic events in patients with unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), or ST-segment elevation MI (STEMI), as well as those undergoing percutaneous coronary intervention (PCI) and stenting [Bhatt DL et al. \u003Cem\u003ENEJM\u003C\/em\u003E 2006; Mehta SR et al. \u003Cem\u003ELancet\u003C\/em\u003E 2001]. However, long-term treatment with clopidogrel is not necessarily appropriate in a broad population of patients at high risk for cardiovascular events. In the CHARISMA trial, the addition of clopidogrel to aspirin did not appear to reduce the combined risk of MI, stroke, or CV death compared with placebo in patients with multiple risk factors but no established disease (ie, primary prevention cohort) [Yusuf S et al. \u003Cem\u003ENEJM\u003C\/em\u003E 2001].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EA new generation of antiplatelet agents are currently under evaluation. For example, prasugrel provides more rapid, potent, and consistent inhibition of platelet function than clopidogrel. Compared with clopidogrel, prasugrel reduced the risk of CV death, MI, and stroke by 19% (p=0.0004) and reduced the risk of stent thrombosis by 52% (p\u0026lt;0.0001) in the TRITON-TIMI 38 trial. However, these gains came at the cost of excess major bleeding, including fatal bleeding (HR 1.32; p=0.03; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Wiviott DS et al. \u003Cem\u003ENEJM\u003C\/em\u003E 2007].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/34\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Efficacy and Safety of Prasugrel vs Clopidogrel in Patients Scheduled for PCI. Primary efficacy endpoint: CV death, MI, and Stroke. Safety Endpoint: TIMI Major Bleeding.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-363430899\u0022 data-figure-caption=\u0022Efficacy and Safety of Prasugrel vs Clopidogrel in Patients Scheduled for PCI. Primary efficacy endpoint: CV death, MI, and Stroke. Safety Endpoint: TIMI Major Bleeding.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/34\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/34\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/34\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/10932\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EEfficacy and Safety of Prasugrel vs Clopidogrel in Patients Scheduled for PCI.\nPrimary efficacy endpoint: CV death, MI, and Stroke. Safety Endpoint: TIMI Major Bleeding.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EProf. Verheugt summarized his presentation by discussing the ideal duration of different therapies for different patient types. For example, he recommended the use of low-dose aspirin (\u0026lt;100 mg) for all patients, adding that the optimal duration of treatment is \u201cforever\u201d.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EProf. Verheugt advised that clopidogrel may be appropriate for 1 year in patients with NSTEMI who were treated with or without PCI, and for STEMI patients who were treated with PCI. For STEMI patients who did not undergo PCI, clopidogrel may be beneficial for approximately 1 month. For both NSTEMI and STEMI patients who were treated with drug-eluting stents, the optimal duration of clopidogrel therapy may be longer than 1 year.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EBalancing the Risks and Benefits of Antithrombotic Therapy\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EBleeding and transfusion risk is high with current antithrombotic treatments, noted Frans Van de Werf, MD, University Hospital Gasthuisberg, Leuven, Belgium. Prof. Van de Werf suggested strategies for balancing the benefits and risks of long-term antithrombotic therapy for patients with NSTEMI or STEMI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EApproximately 15% of patients with NSTEMI require transfusions due to excess bleeding during their hospitalization [Yang J et al. \u003Cem\u003EJACC\u003C\/em\u003E 2005]. Transfusions are associated with an increased risk in 30-day mortality in patients with NSTEMI (OR 3.94, 3.26\u20134.75) and in those with STEMI (OR 3.7; p\u0026lt;0.0001) [Rao SV et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2004; The APEX-AMI Investigators. \u003Cem\u003EJAMA\u003C\/em\u003E 2007], although a causal relationship is difficult to establish.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EProf. Van De Werf offered several recommendations for balancing benefit and risk in this patient population. For example, he recommended performing invasive procedures only when indicated, and suggested considering radial artery access in patients at high risk for bleeding. Coronary artery bypass grafting should be performed after stopping clopidogrel for at least 5 days.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EProf. Van De Werf also suggested using fondaparinux or bivalirudin in patients at high risk for bleeding. Finally, limiting the use of upfront glycoprotein IIb\/IIIa inhibitors to only high-risk NSTEMI patients may also reduce bleeding, although studies are conflicting regarding the potential loss in efficacy, and additional studies are ongoing [EARLY ACS \u2013 Giugliano. \u003Cem\u003EAHJ\u003C\/em\u003E 2005;149:994\u20131002]. Antithrombotic agents should be dosed carefully, especially in elderly, female, or low-weight patients, and in those with renal failure to avoid overdosing these patients who are at increased risk of bleeding. [Alexander. \u003Cem\u003EJAMA\u003C\/em\u003E 2005;294:3108\u201316]. Lastly, Prof. Van De Werf reminded the audience that use of a proton pump inhibitor in patients with a history of gastrointestinal bleeding is now recommended by the updated nSTE-ACS guidelines [Anderson et al. \u003Cem\u003EJACC\u003C\/em\u003E 2007].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2007 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/7\/7\/34.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzm7gd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzm7gd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}