Current practice and limitations of dual antiplatelet therapy in acute coronary syndrome

Prevention and treatment of all phases of cardiovascular disease remains a challenge. Antiplatelet therapy has a paramount place in the management of acute coronary syndromes (ACS), which often precipitates cardiovascular death. Current guidelines of the European Society of Cardiology recommend that all patients should be treated with dual aspirin/clopidogrel antiplatelet therapy during the acute phase, and for up to 12 months in instances of non-ST-elevation ACS. Nonetheless, recurrent cardiovascular events still occur in patients who receive guideline-recommended antiplatelet therapy, and therefore there is room to improve upon the degree and timing of platelet inhibition. The variability of responsiveness to aspirin and clopidogrel among patients who experience ACS has been the focus of intense investigation. Interindividual variation in the degree of platelet inhibition achieved after administration of clopidogrel is marked, and an associated clinically inadequate response occurs in up to 30% of patients (depending upon the platelet aggregation measurement used). In addition, the optimal interval between clopidogrel administration and maximal drug effect is more than 15 h. Development of antiplatelet agents which have more consistent and more rapid action could therefore bring significant advantages over current antiplatelet regimens.