Antiplatelet therapy de-escalation in a patient after percutaneous coronary intervention with a high risk of bleeding

Abstract

According to recommendations of ESC 2020-year, de-escalation of therapy with a P2Y12 receptor inhibitor (transition from prasugrel or ticagrelor to clopidogrel) It can be considered as an alternative strategy of dual antiplatelet therapy (DAPT) for patients with acute coronary syndrome (ACS) who are unsuitable for the use of a strong platelet inhibitor.De-escalation can be performed based on an individual clinical evaluation under the supervision of platelet function testing or CYP2C19 genotyping, depending on the patient’s risk profile and the availability of appropriate diagnostic methods. The optimal dosage of strong P2Y12 receptor inhibitors, such as ticagrelor or prasugrel is not entirely clear and is especially difficult to define for patients of Asian nationality.The article describes a clinical case of antiplatelet therapy de-escalation, particularly a dose reduction of the potent P2Y12 receptor inhibitor ticagrelor in a patient after percutaneous coronary intervention (PCI) with a high risk of bleeding based on platelet function determination and genetic testing. A 47-year-old patient of Kazakh nationality was hospitalized with gastrointestinal bleeding.Given bleeding type 3 by BARC (Bleeding Academic Research Consortium) associated with DAPT, it was decided to apply a strategy to de-escalate antiplatelet therapy under the control of platelet function testing (PFT) and genetic testing.In this case, replacement of ticagrelor with the weak P2Y12 receptor inhibitor clopidogrel was not possible as the patient appeared to be a carrier of the CYP2C19*2 polymorphism contributing to loss of function of the cytochrome P-450(CYP) enzyme.

Keywords

• de-escalation
• acute coronary syndrome
• percutaneous coronary inter¬vention
• p2y12 receptor inhibitor
• residual platelet reactivity
• cyp2c19 poly¬mor¬phism