La lesión que la propia intervención coronaria percutánea (ICP) provoca en la pared arterial pone en marcha la activación y agregación plaquetarias. Por este motivo, todos los pacientes deben estar eficazmente antiagregados durante y después de la intervención. La combinación de aspirina más clopidogrel es hoy día el tratamiento antiplaquetario oral estándar para los pacientes tratados con ICP. En los pacientes que no estén tomando aspirina, se deben administrar 500mg por vía oral al menos 3h antes de la intervención, o 300mg por vía intravenosa en el momento de ésta; y después de la ICP se administrarán 100mg diarios de aspirina de forma indefinida. El clopidogrel debe administrarse también antes de la ICP, idealmente en dosis de carga de 300mg al menos 6 h antes del procedimiento. Cuando esto no sea posible, y especialmente en pacientes de alto riesgo o en aquellos con una demostrada menor respuesta al clopidogrel, como por ejemplo los pacientes diabéticos, se debe considerar la administración de dosis más altas de carga de clopidogrel, aunque el beneficio clínico de esta medida es todavía discutido. Tras la implantación de un stent convencional se mantendrá el clopidogrel durante un mes, y tras un stent recubierto de fármacos antiproliferativos, durante 3-12 meses. Mientras tanto, y con el objetivo de superar algunas de las limitaciones del clopidogrel, continúa la búsqueda del antagonista «ideal» de los receptores plaquetarios del adenosindifosfato (ADP), es decir, un fármaco que, administrado por vía oral, sea reversible, con un rápido efecto de acción, un alto grado de inhibición y sin resistencias. Fármacos antiplaquetarios potentes como el prasugrel y el AZD6140 han demostrado ya tener un perfil de seguridad similar al clopidogrel, y su eficacia clínica está siendo valorada en grandes ensayos multicéntricos que persiguen facilitar y optimizar el tratamiento de los pacientes tratados con ICP.
Palabras clave
Aspirina
Clopidogrel
Intervención coronaria percutánea
Este artículo solo puede leerse en
pdf
Bibliografía
[1.]
C. Patrono, F. Bachmann, C. Baigent, C. Bode, R. De Caterina, B. Charbonnier, et al.
Expert consensus document on the use of antiplatelets agents. The Task Force on the use on antiplatelets agents in patients with atherosclerotic cardiovascular disease of the European Society of Cardiology.
Eur Heart J, (2004), 25 pp. 166-181
[2.]
M.P. Savage, S. Goldberg, A.A. Bove, E. Deutsch, G. Vetrovec, R.G. Macdonald, et al.
Effect of thromboxane A2 blockade on clinical outcome and restenosis after successful coronary angioplasty. Multi-Hospital Eastern Atlantic Restenosis Trial (M-HEART II).
Circulation, (1995), 92 pp. 3194-3200
[3.]
The Anti-Thrombotic Trialists’ Collaboration.
Collaborative metaanalysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.
BMJ, (2002), 324 pp. 71-86
[4.]
S. Silber, P. Albertsson, F.F. Avilés, P.G. Camici, A. Colombo, C. Hamm, et al.
Guidelines for percutaneous coronary interventions. The Task Force for percutaneous coronary interventions of the European Society of Cardiology.
Eur Heart J, (2005), 26 pp. 804-847
[5.]
T.A. Nguyen, J.G. Diodati, C. Pharand.
Resistance to clopidogrel: a review of the evidence.
J Am Coll Cardiol, (2005), 45 pp. 1157-1164
[6.]
J.J. Thebault, G. Kieffer, R. Gariou.
Single-dose pharmacodynamics of clopidogrel.
Semen Thromb Hemost, (1999), 25 pp. 3-8
[7.]
M.J. Quinn, D.L. Bhatt, F. Zidar, D. Vivekananthan, D.P. Chew, S.G. Ellis, et al.
Effect of clopidogrel pretreatment on inflammatory marker expression in patients undergoing percutaneous coronary intervention.
Am J Cardiol, (2004), 93 pp. 679-684
[8.]
D.P. Vivekananthan, D.L. Bhatt, D.P. Chew, F.J. Zidar, A.W. Chan, D.J. Moliterno, et al.
Effect of clopidogrel pretreatment on periprocedural rise in C-reactive protein after percutaneous coronary intervention.
Am J Cardiol, (2004), 94 pp. 358-360
[9.]
Z. Xiao, P. Theroux.
Clopidogrel inhibits platelet-leukocyte interactions and thrombin receptor agonist peptide-induced platelet activation in patient with an acute coronary syndrome.
J Am Coll Cardiol, (2004), 43 pp. 1982-1988
[10.]
S. Mehta, S. Yusuf, R. Peters, M.E. Bertrand, B.S. Lewis, M.K. Natarajan, et al.
Effects of pre-treatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study.
Lancet, (2001), 358 pp. 527-533
[11.]
S.R. Steinhubl, P.B. Berger, T. Mann 3rd, E.T. Fry, A. DeLago, C. Wilmer, For the CREDO Investigators, et al.
Clopidogrel for the reductions of events during observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention.
JAMA, (2002), 288 pp. 2411-2420
[12.]
A.W. Chan, D.J. Moliterno, P.B. Berger, G.W. Stone, P.M. DiBattiste, S.L. Yakubov, et al.
Triple antiplatelet therapy during percutaneous coronary intervention is associated with improved outcome including one-year survival: results from the Do Tirofiban and ReoPro Give Similar Efficacy Outcome Trial (TARGET).
J Am Coll Cardiol, (2003), 42 pp. 1188-1195
[13.]
D.J. Angiolillo, A. Fernández-Ortiz, E. Bernardo, C. Ramírez, M. Sabate, C. Bañuelos, et al.
High clopidogrel loading dose during coronary stenting: effects on drug response and interindividual variability.
Eur Heart J, (2004), 25 pp. 1903-1910
[14.]
A. Kastrati, J. Mehilli, H. Schuhlen, J. Dirschinger, F. Dotzer, J.M. Ten Berg, For the Intracoronary Stenting and Antithrombotic Regimen-Rapid Early Action for Coronary Treatment (ISAR-REACT) study investigators, et al.
A clinical trial of abciximab in elective percutaneous coronary intervention after pre-treatment with clopidogrel.
N Engl J Med, (2004), 350 pp. 232-238
[15.]
D.E. Kandzari, P.B. Berger, A. Kastrati, S.R. Steinhubl, J. Mehilli, F. Dotzer, For the ISAR-REACT study investigators, et al.
Influence of treatment duration with a 600 mg dose of clopidogrel before percutaneous coronary revascularization.
J Am Coll Cardiol, (2004), 44 pp. 2133-2136
[16.]
A.J. Quick.
Salicylates and bleeding: the aspirin tolerante test.
Am J Med Sci, (1966), 252 pp. 265-269
[17.]
P.A. Gurbel, K.P. Bliden, K.M. Hayes, J.A. Yoho, W.R. Herzog, U.S. Tantry.
The relation of dosing to clopidogrel responsiveness and the incidence of high post-treatment platelet aggregation in patients undergoing coronary stenting.
J Am Coll Cardiol, (2005), 45 pp. 1392-1396
[18.]
V.L. Serebruany, S.R. Steinhubl, P.B. Berger, A.I. Malinin, D.L. Bhatt, E.J. Topol.
Variability in platelet reponsiveness to clopidogrel among 544 individuals.
J Am Coll Cardiol, (2005), 45 pp. 246-251
[19.]
D.J. Angiolillo, A. Fernández-Ortiz, E. Bernardo, C. Ramírez, M. Sabate, P. Jiménez-Quevedo, et al.
Platelet function profiles in type 2 diabetics on combined aspirin and clopidogrel treatment.
Diabetes, (2005), 54 pp. 2430-2435
[20.]
D.J. Angiolillo, A. Fernández-Ortiz, E. Bernardo, C. Barrera Ramírez, M. Sabate, C. Fernández, et al.
Platelet aggregation according to body mass index in patints undergoing coronary stenting: should clopidogrel loading dose be weight adjusted?.
J Invas Cardiol, (2004), 16 pp. 169-174
[21.]
D.J. Angiolillo, A. Fernández-Ortiz, E. Bernardo, F. Alfonso, M. Sabate, C. Fernández, et al.
PLA polymorphism and platelet reactivity following clopidogrel loading dose in patients undergoing coronary stent implantation.
Blood Coagul Fibrinolysis, (2004), 2 pp. 88-93
[22.]
D.J. Angiolillo, A. Fernández-Ortiz, E. Bernardo, C. Ramírez, J. Escaned, R. Moreno, et al.
807 C/T polymorphism of the glycoprotein Ia gene and pharmacogenetic modulation of platelet response to dual antiplatelet treatment.
Blood Coagul Fibrinolysis, (2004), 15 pp. 427-433
[23.]
D.J. Angiolillo, A. Fernández-Ortiz, E. Bernardo, C. Ramírez, U. Cavallari, E. Trabetti, et al.
Variability in platelet aggregation following sustained aspirin and clopidogrel treatment in patients with coronary heart disease and influence of the 807 C/T polymorphism of the glycoprotein Ia gene.
Am J Cardiol, (2005), 96 pp. 1095-1099
[24.]
Angiolillo DJ, Fernández-Ortiz A, Bernardo E, Ramírez C, Ramírez C, Cavallari U, et al. Contribution of gene sequence variations of the hepatic cytochrome P450 3A4 enzyme to variability in individual responsiveness to clopidogrel. Arterioscler Thromb Vasc Biol. 2006. En prensa.
[25.]
D.J. Angiolillo, A. Fernández-Ortiz, E. Bernardo, C. Ramírez, U. Cavallari, E. Trabetti, et al.
Identification of low responders to a 300-mg clopidogrel loading dose in patients undergoing coronary stenting.
Thromb Res, (2005), 116 pp. 491-497
[26.]
A. Fernández-Ortiz, C. Macaya.
Subestudio PCI-CURE: tratamiento antiagregante en los pacientes sometidos a intervencionismo coronario tras un síndrome coronario agudo.
Rev Esp Cardiol, (2003), 3 pp. A22-30
[27.]
S.C. Smith, T.E. Feldman, J.W. Hirshfeld Jr, A.K. Jacobs, M.J. Kern, S.B. King 3rd, et al.
ACC/AHA/SCAI 2005 Guideline Update for percutaneous coronary intervention: summary article.
J Am Coll Cardiol, (2006), 47 pp. 216-235
[28.]
M.K. Hong, G.S. Mintz, C.W. Lee, J.M. Song, K.H. Han, D.H. Kang, For the Asian Paclitaxel-Eluting Stent Clinical Trial Investigators, et al.
Paclitaxel coating reduces in-stent intimal hyperplasia in human coronary arteries: a serial volumetric intravascular ultrasound analysis from the Asian Paclitaxel-Eluting Stent Clinical Trial (ASPECT).
Circulation, (2003), 107 pp. 517-520
[29.]
V. Pasceri, A. Granatelli, C. Pristinio, F. Pellicia, B. Pironi, G. Richichi.
High-risk of trombosis of Chipre stent in patients not taking ticlopidone or clopidogrel.
Am J Cardiol, (2003), 92 pp. L91
[30.]
R. Moreno, C. Fernández, R. Hernández, F. Alfonso, D.J. Angiolillo, M. Sabate, et al.
Drug-eluting stent trombosis. Results from a pooled análisis including 10 randomized studies.
J Am Coll Cardiol, (2005), 45 pp. 954-959
[31.]
M. Sabate, G. Pimentel, C. Prieto, J.M. Corral, C. Banuelos, D.J. Angiolillo, et al.
Intracoronary brachytherapy after stenting de novo lesions in diabetic patients: results of a randomized intravascular ultrasound study.
J Am Coll Cardiol, (2004), 44 pp. 520-527
[32.]
Y. Niitsu, J.A. Jakubowski, A. Sugidachi, F. Asai.
Pharmacology of CS-747 (prasugrel, LY640315), a novel, potent antiplatelet agent with in vivo P2Y12 receptor antagonist activity.
Semin Thromb Hemost, (2005), 31 pp. 184-194
[33.]
S.D. Wiviott, E.M. Antman, K.J. Winters, G. Weerakkody, S.A. Murphy, B.D. Behounek, et al.
Randomized comparison of prasugrel (CS-747, LY640315), a novel thienopyridine P2Y12 antagonist, with clopidogrel in percutaneous coronary intervention: results of the Joint Utilization of Medications to Block Platelets Optimally (JUMBO)-TIMI 26 trial.
Circulation, (2005), 111 pp. 3366-3373
[34.]
J.J. Van Giezen, R.G. Humphries.
Preclinical and clinical studies with selective reversible direct P2Y12 antagonists.
Semin Thromb Hemost, (2005), 31 pp. 195-204
[35.]
C.P. Cannon, S. Husted, R.F. Storey, R.A. Harrington, C. Watkins, S. Hill, The DISPERSE 2 Investigators. The DISPERSE 2 Trial: safety, tolerability and preliminary efficacy of AZD6140, the first oral reversible ADP receptor antagonist, compared with clopidogrel in patients with non-ST segment elevation acute coronary syndrome, et al.
Circulation, (2005), 112 pp. 906
[36.]
G. Montalescot, On behalf of the Albion Investigators.
Assessment of the best loading dose of clopidogrel to blunt platelet activation, inflammation and ongoing necrosis.
Eur Heart J, (2005), 26 pp. 484
[37.]
N. Von Beckerath, D. Taubert, G. Pogatsa-Murray, E. Schomig, A. Kastrati, A. Schomig.
Absorption, metabolization, and antiplatelet effects of 300-, 600-, and 900-mg loading doses of clopidogrel: results of the ISAR-CHOICE (Intracoronary Stenting and Antithrombotic Regimen: Choose Between 3 High Oral Doses for Immediate Clopidogrel Effect) Trial.
Circulation, (2005), 112 pp. 2946-2950
[38.]
G. Patti, G. Colonna, V. Pasceri, L.L. Pepe, A. Montinaro, G. Di Sciascio.
Randomized trial of high loading dose of clopidogrel for reduction of periprocedural myocardial infarction in patients undergoing coronary intervention: results from the ARMYDA-2 (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty) study.
Circulation, (2005), 111 pp. 2099-2106
Copyright ©
2006. Sociedad Española de Cardiología