Secondary prevention of acute coronary syndromes

Objective: To review the role of antithrombotic therapy for prevention of acute coronary syndrome (ACS) recurrence following hospital discharge. Data Sources: Recent (1995-2003) published scientific literature, as identified by the authors through Medline searches, using the terms acute coronary syndromes, antithrombotic, antiplatelet, clinical trials, and reviews on treatment. Study Selection: Recent systematic English-language review articles and reports of controlled randomized clinical trials were screened for inclusion. Data Synthesis: Despite aspirin prophylaxis, the biochemical stimulus for thrombus formation persists for several months after an acute coronary event. Ideally, multiple antithrombotic agents with complementary mechanisms of action should be used for secondary prevention of ischemic events after hospital discharge. Aspirin and clopidogrel (Plavix - Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership) have synergistic antiplatelet effects, and long-term combination therapy with these agents is currently recommended for patients with ACS. The combination of aspirin and warfarin offers potential advantages as an antithrombotic regimen for secondary prevention of ACS (i.e., suppression of the coagulation cascade and platelet function); however, the optimal balance between bleeding risk and antithrombotic benefit is difficult to achieve in practice. Conclusion: Persistence of the prothrombotic stimulus after an acute coronary event provides a clear rationale for long-term antithrombotic therapy to prevent the recurrence of ischemic events.