Article

Novel antiplatelet strategies in acute coronary syndromes

Author and Disclosure Information

 

References

One agent in this class that is being studied extensively is SCH 530348, an oral thrombin receptor antagonist with potent antiplatelet activity. Its peak antiplatelet potency is achieved within hours when a loading dose is given, and within days without a loading dose. Wearing-off of the action of SCH 530348 takes weeks. 24

Inhibition of platelet aggregation with thrombin receptor antagonists is measured in response to the thrombin receptor antagonist peptide (TRAP), not ADP. The proportion of subjects treated with SCH 530348 who achieve greater than 80% inhibition of platelet aggregation to 15 μM of TRAP ranges from 91% (with 0.5 mg of SCH 530348) to 100% (with 1.0 mg and 2.5 mg) at both 30 days and 60 days. 25

Clinical effects in placebo-controlled trials

SCH 530348 was studied in the Thrombin Receptor Antagonist (TRA)–PCI trial, a dose-ranging study in which patients were randomized to one of three oral loading doses of the study drug (10 mg, 20 mg, or 40 mg) on top of a clopidogrel loading dose before undergoing cardiac catheterization for planned PCI; patients were then randomized to one of three maintenance doses of SCH 530348 (0.5 mg, 1.0 mg, or 2.5 mg) or placebo (depending on loading therapy) for 60 days. 25

Among the 573 patients undergoing PCI , the rate of TIMI major or minor bleeding was not significantly higher with any dose of SCH 530348 compared with placebo, 25 supporting the hypothesis that thrombin receptor antagonism inhibits platelet aggregation without a significant increase in bleeding.

Although the TRA-PCI study was not powered to detect differences in clinical event rates, a reduction in the rate of major adverse cardiovascular events was observed in a dose-dependent manner with SCH 530348 compared with placebo in the PCI cohort. 25

On the basis of the TRA-PCI trial, a pair of phase 3 trials of SCH 530348 have been launched—the Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events (TRA 2°P-TIMI 50) study and the Thrombin Receptor Antagonist for Clinical Event Reduction in ACS (TRA-CER) study.

TRA 2°P-TIMI 50 is a multinational double-blind study enrolling 19,500 patients with prior MI or stroke or with existing peripheral arterial disease. Patients are being randomized to placebo plus standard medical care (including aspirin and clopidogrel) or to 2.5 mg of SCH 530348 once daily plus standard medical care. The primary end point is the composite of cardiovascular death, MI, urgent coronary revascularization, or stroke. 26

TRA-CER is a multinational double-blind study with planned enrollment of 10,000 patients with non-ST-segment-elevation MI. Patients are being randomized to placebo plus standard medical care (including aspirin or clopidogrel) or to SCH 530348 (using the oral 40-mg loading dose and a maintenance dose of 2.5 mg once daily) plus standard medical care. The primary end point is the composite of cardiovascular death, MI, rehospitalization for ACS, urgent coronary revascularization, or stroke. The key secondary end point is the composite of cardiovascular death, MI, or stroke. 27

COMPARATIVE CONSIDERATIONS

Table 1 provides an overview of the pharmacologic properties of the antiplatelet therapies reviewed here. While I would caution against making direct comparisons among agents across this table, in light of the wide variability in how platelet aggregation studies are conducted and the lack of head-to-head comparisons of novel agents, this table provides useful benchmarks for general comparison.

Inhibition of platelet aggregation

Next Article:

Related Articles