Injectable antiplatelet therapies in acute coronary syndromes: Current status and Emerging Therapies. A position paper of the Task Force of Antithrombotic therapy of the ACVC

Injectable antiplatelet agents can provide immediate and effective platelet inhibition in patients with acute coronary syndromes (ACS). These agents are able to overcome many of the limitations of oral antiplatelet agents, and maybe of particular benefit in patients with ST-elevation myocardial infarction (STEMI), especially those presenting with cardiogenic shock or rescuscitated cardiac arrest. In these patients, factors such as vomiting, altered physiology, sedation, mechanical ventilation or therapeutic hypothermia can impair drug absorption, reducing the intended antiplatelet effect and increasing ischaemic risk. Intravenous aspirin is used widely in patients with ACS, while the absorption of oral P2Y12 inhibitors is often delayed, and the intravenous P2Y12 inhibitor cangrelor can achieve almost complete platelet inhibition within minutes. While use of the glycoprotein IIb/IIIa inhibitors (GPI) eptifibatide and tirofiban is decreasing, typically reserved for thrombotic complications or no reflow following PCI, recently zalunfiban, a novel subcutaneously administered GPI has been shown to improve reperfusion before revascularisation in patients with STEMI when given at first medical contact. In this review, we dicuss the rationale and potential benefits of injectable antiplatelet medications, including currently available agents and those in development or being tested in clinical trials. While the benefit of injectable medications on hard clinical endpoints such as major adverse cardiac events remains unclear for an allcomers ACS population, there is emerging data that these agents achieve rapid platelet inhibition, improve coronary flow and clinical outcomes particular in high risk ACS patients, such as those with cardiogenic shock.