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Fibrinolytic, antithrombotic, and antiplatelet drugs in acute coronary syndromes 

Fibrinolytic, antithrombotic, and antiplatelet drugs in acute coronary syndromes
Fibrinolytic, antithrombotic, and antiplatelet drugs in acute coronary syndromes

Peter Sinnaeve

and Frans Van de Werf



The current ESC STEMI guidelines recommend a half-dose of tenecteplase in patients above 75 years of age (IIaB recommendation), based on results of the STREAM trial.

The GEMINI-ACS-1 trial showed that low-dose rivaroxaban with either clopidogrel or ticagrelor but without aspirin was not superior to conventional dual antiplatelet therapy in patients with an acute coronary syndrome. Major bleeding complications were similar with both antithrombotic strategies.

The REG1 system, which combines the factor IXa antagonist pegnivacogin and its antagonist anivamersen, was not shown to be superior to bivalirudin in stable and unstable patients undergoing PCI in the REGULATE-PCI study, which was stopped prematurely because of serious allergic reactions to REG1.

The ATLANTIC trial showed that prehospital administration of ticagrelor is safe while not improving indices of coronary reperfusion before primary PCI.

Three recent large clinical trials (MATRIX, HEAT-PCI, and VALIDATE-SWEDEHEART) compared bivalirudin to monotherapy UFH (without routine GPI use), and showed no benefit of bivalirudin, neither in ischemic risk or bleeding risk, in contrast to older studies comparing bivalirudin to UFH with routine GPI use.

Updated on 22 February 2018. The previous version of this content can be found here.
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date: 28 January 2022

Antithrombotic therapy is a major cornerstone in the treatment for acute coronary syndromes, as thrombus formation upon a plaque rupture or an erosion plays a pivotal role in non-ST-segment elevation as well as ST-segment elevation acute coronary syndromes. Both acute and long-term oral antiplatelet therapies, targeting specific platelet activation pathways, have demonstrated significant short- and long-term benefits. The use of anticoagulants is currently largely confined to the acute setting, except in patients with a clear indication for long-term treatment, including atrial fibrillation or the presence of intraventricular thrombi. Despite the benefit of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction, fibrinolysis continues to play an important role throughout the world as well. In this chapter, the fibrinolytic, antiplatelet, and anticoagulant agents used in the management of acute coronary syndrome patients are discussed.

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