Anti-Coagulants Recommended for Prevention of Atherosclerotic Cardiovascular Disease

Peter Grant, MD

The world of cardiovascular disease in diabetes is broad and all-encompassing with devastating physical and mental complications.

Atherosclerotic cardiovascular disease can lead to a buildup of cholesterol blood in the body, causing obstruction of blood flow.

Peter Grant, MD, Professor of Medicine at the University of Leeds, United Kingdom, offered insight into the anti-coagulation agents that have been recommended in the prevention of atherosclerotic cardiovascular disease in recent years.

In a presentation at The Metabolic Institute of America’s (TMIOA) 2021 Heart in Diabetes sessions in New York, NY, Grant detailed the effects of atherosclerotic cardiovascular disease on patients, the implications of cardiovascular diseases on the body, and prevention and management methods.

“One of the things we’ve come to realize over the last 25 years is that the phenotype of atherosclerotic cardiovascular disease is complex,” Grant said. “The metabolic milieu of diabetes which exists in longstanding diabetes interacts with the inflammatory and thrombotic processes to cause inflammatory thrombotic changes.”

The changes brought on by thrombotic processes have led to complications with macrophages, lymphocytes, as well as platelets and coagulation proteins.

Additionally, atherosclerotic cardiovascular disease has been known to lead to the development of cardiovascular disease in diabetes.

From there, complications from diabetes could result in fixed coronary artery disease, acute coronary syndromes, heart failure and sudden death.

“So, the whole spectrum has thrombosis at its heart, which means that we need treatments that are going to prevent this faster occlusion from occurring,” Grant said.

According to Grant, thrombosis could be divided into 2 components consisting of the fluid phase (coagulation proteins and fibrinolysis proteins) and the cellular phase (platelets and microphages).

“In the arterial system, platelet adhesion to the fibrin leads to the formation of a thick, dense clot, which enhances the risk of obstructive arterial disease.”

In addition to coagulation, thrombosis has lead to the activation of platelets in the body that adhere to damaged regions and inflammation that pushes arterial wall to an inflammatory state.

However, therapeutic approaches to arterial thrombotic risk are available.

Grant divide the approached into 2 categories, which were anti-platelet agents and anticoagulants.

In previous studies, aspirin lead to an 11% reduction in cardiovascular events, though the “relatively high risk” it presented regarding breathing complications have raised concerns. As such, aspirin was considered unwarranted in uncomplicated diabetes prevention.

Grant also referenced P2Y12 inhibitors that bind to protein receptors in the body. Oral anti-platelet therapies such as prasugrel, ticagrelor, and clopidogrel had seen great success in recent trials, though prasugrel was deemed superior in all-cause death and stent thrombosis management.

Grant cited guidelines from that American Heart Association that suggested that asymptomatic patients be treated with single anti-platelet therapy, and high risk patients be treated with dual anti-platelet therapy followed by single anti-platelet therapy.

He added that dual anti-platelet therapy should continue for up to 3 years depending on bleeding risk and be strictly individualized to each patient.

Additionally, Grant hypothesized that discontinuing aspirin rather that P2Y12 inhibitors could lead to better outcomes, and suggested prasugrel treatment be avoided by patients at risk for cellular vascular events.

“Anti-platelet therapy has a pivotal role in the prevention and management of cardiovascular disease in patients with diabetes,” Grant said “But it should be remembered, and this meeting is largely about the fact, that there are many other things that have to be looked after and managed as well.”