Modifying Antiplatelet Therapy: ARC Consensus Aims to Standardize Definitions

The language used to describe either escalation or de-escalation of antiplatelet therapy by modifying the type, dose, or number of medications in patients with coronary artery disease has been standardized in a new Academic Research Consortium (ARC) consensus document.

In recent years, trials have examined the impact of various strategies for intensifying or pulling back on the degree of platelet inhibition, with de-escalation in particular being “one of the hottest topics right now when it comes to antiplatelet therapy,” according to Dominick Angiolillo, MD, PhD (University of Florida College of Medicine – Jacksonville), one of the chairs of the document along with Davide Capodanno, MD, PhD (University of Catania, Italy).

Practice guidelines contain recommendations on the use of dual antiplatelet therapy (DAPT) in patients undergoing PCI, those being treated medically for ACS, and others, but the number of ways in which such therapy can be modified to achieve the best balance between bleeding risk and ischemic protection has increased in recent years, Angiolillo told TCTMD.

“What has happened is that the approach towards defining such modalities of modifying the intensity of platelet inhibition—particularly in the area that has been most subject to investigation, which is de-escalation of antiplatelet therapy—has led to a lot of confusion about the different modalities that are out there,” he said. “And many clinicians would be defining different modalities with the same name. So we needed to come up with some type of consensus on how to define these modalities, particularly of de-escalation, so that we’re all speaking the same language.”

The ARC consensus document, published in the June 20/27, 2023, issue of Circulation, was produced by a group of international experts on antiplatelet therapy, with input from the US Food and Drug Administration and the Japanese Pharmaceuticals and Medical Devices Agency.

In the paper, which doesn’t pertain to patients with a baseline indication for oral anticoagulation, the authors break the discussion into two larger sections—de-escalation and escalation. Within each of those sections, they review evidence regarding how to modify therapy to achieve those goals by switching between more- and less-potent agents (or vice versa), by decreasing or increasing dose, and by discontinuing or adding on medications.

Switching between agents for either de-escalation or escalation may be guided by clinical judgment or the results of platelet function testing or genotyping, they note.

In terms of defining the various strategies, the approach “was actually rather simplistic because these definitions are not just for experts in the field but for the entire cardiovascular community when they’re speaking about antiplatelets, to make sure that we are using definitions that are easy to remember and to apply,” Angiolillo said.

He underscored that the purpose of the document is not to make recommendations about which strategies should be used, and when. “The goal of this document is to provide a framework,” said Angiolillo, “so that we can come up with very clear-cut definitions that can accordingly be used in the future by others as they design trials or they apply changes in therapy in their clinical practice.”