New Guidelines Released for Genetic Testing Post-PCI

New Guidelines Released for Genetic Testing Post-PCI

New consensus statements have been released on using platelet function/genetic testing to decide antiplatelet treatment after percutaneous coronary intervention (PCI). As different P2Y12receptor inhibitors (i.e. clopidogrel, prasugrel, and ticagrelor) have been approved for post-PCI treatment more physicians have started prescribing individualized regimens.  An international expert panel’s updated recommendations for such prescribing were recently published in JAAC: Cardiovascular Interventions.

PCI is one of the most common cardiac procedures in medicine.  One potential side effect is embolization leading to cardiac arrest. But the advent of aggressive antiplatelet therapy has significantly reduced the incidence of this.Today, standard treatment for post-PCI patients is dual-antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor.

Routine use of genetic testing or PFT has not typically been recommended post-PCI.  But recent data prompted wider use of these tests becausethe available receptor inhibitors have varying levels of potency.  Clopidogrel is a moderate P2Y12 inhibitor, while ticagrelor or prasugrel are potent inhibitors of that receptor. The new consensus statements help physicians determine when to switch a patient to a different drug. As a result, physicians may want to escalate or de-escalate P2Y12 therapy depending on the patient’s response. Prescribing can also be influenced by the patient’s clinical presentation (stable coronary disease vs. acute coronary syndrome), the disease stage (early vs. long-term treatment) and the patient’s other risks for ischemic and bleeding complications.

The authors of the consensus concluded that “the results of these tests should never be used alone but must be integrated with numerous other clinical, angiographic, procedural and socio-economic variables, which together should guide optimal DAPT decisions. Ultimately, it needs to be acknowledged that different health care systems across the globe may have an impact on the uptake and adherence to different P2Y12inhibitors as well as reimbursement for PFT or genetic testing.” They added that ongoing trials in this field should focus on DAPT escalation, DAPT de-escalation, and timing of surgery, to “further refine the field of personalizing P2Y12receptor inhibitor treatment in patients undergoing PCI.”

This consensus paper was written by an international group of leaders from North America, Asia and Europe with expertise in the field of antiplatelet treatment. It updates two prior consensus papers on this topic and summarizes recommendations for the selective use of platelet function testing (PFT) and genotyping in patients undergoing PCI.The lead authors were Dirk Sibbing, M.D., Department of Cardiology, LMU München, Munich, Germanyand Daniel Aradi, M.D., assistant professor at Semmelwis University Heart and Vascular Center.