Novel anti-thrombotic therapy in acute coronary syndromes

Despite recent developments in revascularisation, anti-platelet and anti-thrombotic therapies, patients with acute coronary syndromes (ACS) remain at increased risk of recurrent atherothrombotic events. Dual anti-platelet therapy comprising aspirin and platelet P2Y12 receptor inhibition has become the cornerstone of therapy in ACS. However, thrombin-mediated pathways, which contribute to platelet activation and are responsible for the formation of fibrin clot, remain active following initial plaque rupture. Recently, orally administered drugs which directly target thrombin, factor Xa or thrombin-mediated platelet activation have been developed. Efficacy outcomes in trials of these novel anti-thrombotic agents in ACS have yielded mixed results and their adoption in clinical practice is currently hampered due to a penalty of increased bleeding. To date, the direct Xa inhibitor rivaroxaban and the protease-activated receptor-1 antagonist atopaxar have shown most promise and require further evaluation to determine their role in ACS management.