Investigational drugs for the treatment of acute myocardial infarction: focus on antiplatelet and anticoagulant agents

ABSTRACT

Background: Advances in our understanding of the complex pathophysiologic mechanisms responsible for high-risk atherosclerotic plaque rupture resulting in acute myocardial infarction (AMI) have led to the development of numerous antiplatelet and anticoagulant agents for treatment of AMI.

Areas covered: We review various antithrombotic drugs which were recently investigated for the treatment of AMI. A MEDLINE search for relevant articles on newer antiplatelet agents and anticoagulants drugs for the treatment of AMI was performed, and important original investigations were reviewed. We also briefly discuss agents that completed evaluation and were recently recommended by expert guidelines.

Expert opinion: The antiplatelet agents cangrelor and vorapaxar and the anticoagulant rivaroxaban, have shown promise for the reduction of ischemic events when administered during, and in the acute phase following AMI. However, these agents have not been compared with more potent P2Y₁₂ inhibitors, prasugrel, and ticagrelor. Finding an optimum combination of these agents to achieve an appropriate risk (bleeding) – benefit (reduction in ischemic events) balance is challenging. Further evaluation of agents that show promise is important for enhancing our armamentarium of pharmacologic agents for the successful treatment of AMI.

Trial registration: ClinicalTrials.gov identifier: NCT01042964.

Trial registration: ClinicalTrials.gov identifier: NCT01020383.

Trial registration: ClinicalTrials.gov identifier: NCT03312855.

Trial registration: ClinicalTrials.gov identifier: NCT02545933.

Trial registration: ClinicalTrials.gov identifier: NCT03234114.

KEYWORDS:

• Acute myocardial infarction
• acute coronary syndromes
• antiplatelet
• anticoagulant
• cangrelor
• vorapaxar
• rivaroxaban
• dabigatran

Article highlights

• Ischemic heart disease (IHD) continues to be a major contributor to health-care burden and was the leading cause of all health loss globally. The pathophysiology strongly involves the activation of platelets and coagulation factors, resulting in the formation and progression of the pathogenic thrombus.

• Along with reperfusion and standard of care drugs like beta-adrenergic blockers and statins, current standard treatment of AMI includes the use of dual antiplatelet therapies, and parenteral anticoagulation

• Recent research on AMI is focused on developing new therapies to overcome existing challenges (route of administration, onset and offset of action) and to improve clinical outcomes.

• Of the newer drugs studied, the antiplatelet agents cangrelor and vorapaxar and anticoagulant agent rivaroxaban (at a low dose) have shown promise for the reduction of ischemic events when administered during, and in the acute phase following ACS in addition to standard treatment, although significant increased bleeding risk was noted.

Further evaluation of promising agents, to achieve an appropriate risk (bleeding) – benefit (reduction in ischemic events) balance, is important to increase the cardiologists’ armamentarium of pharmacologic agents for the successful treatment of AMI patients.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This paper was not funded.