Contact Person

Dr. Elinor Switzer

Managing Editor

Phone: +49 (0)711 - 8931-230
Fax: +49 (0)711 - 8931-323
send an Email


High platelet reactivity – the challenge of prolonged anticoagulation therapy after ACS

Journal: Thrombosis and Haemostasis
ISSN: 0340-6245

Theme Issue
High on-treatment platelet reactivity

Issue: 2013: 109/5(May) pp. 769-975
Pages: 799-807

High platelet reactivity – the challenge of prolonged anticoagulation therapy after ACS

M. A. Brouwer (1), J. Jaspers Focks (1), F. W. A. Verheugt (2)

(1) Department of Cardiology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands; (2) Cardiology, Medical Centre, Radboud University Nijmegen, Nijmegen, Netherlands


Clinical trials, heparins, direct antithrombin agents, oral anticoagulants, coagulation inhibitors, coronary syndrome


Despite dual antiplatelet therapy (DAPT), one-year event rates after acute coronary syndrome (ACS) vary from 9–12%. The development of novel oral anticoagulants (NOAC) without a need for monitoring has initiated renewed interest for prolonged adjunctive anticoagulation. Importantly, the cornerstone of treatment after ACS consists of long-term DAPT. In that context, the NOACs have only been tested as adjunctive therapy. Of all new agents, only rivaroxaban –in a substantially lower dose than used for atrial fibrillation– has been demonstrated to improve outcome, albeit at the cost of bleeding. In selected cases, adjunctive therapy with dose-adjusted vitamin-K antagonists (international normalized ratio [INR] 2.0–3.0) can be considered as well. These two strategies of prolonged anticoagulation can be considered in case of ‘high platelet reactivity’, i.e. in patients at high risk of recurrent thrombotic events despite DAPT. Both during admission and after discharge for ACS, the use of NOACs in doses indicated for atrial fibrillation is strictly contra-indicated in patients on DAPT. In case of post-discharge anticoagulation therapy for atrial fibrillation, patients should preferably receive vitamin-K antagonists (INR 2.0–3.0), with discontinuation of one antiplatelet agent as soon as clinically justifiable. Importantly, the impact of prolonged anticoagulation (low-dose rivaroxaban, vitamin-K antagonists) as adjunctive to DAPT after ACS has not been addressed with the most potent antiplatelet agents (prasugrel, ticagrelor) and merits further study. Despite the potential indication of prolonged oral anticoagulation as adjunctive treatment, it remains to be established whether anticoagulation therapy could also be an alternative for either aspirin or thienopyridine treatment in selected ACS patients on DAPT.

You may also be interested in...

Karin Wåhlander1 , Maria Eriksson-Lepkowska 1 , Per Nyström 1 , Ulf G. Eriksson1 ,Troy C. Sarich 2 , Juan J. Badimon3 , Inge Kalies1 , Margareta Elg1 , Anders Bylock

Thromb Haemost 2006 95 3: 447-453


Theme Issue Article for Theme Issue "New oral anticoagulants"

G. J. Hankey (1, 2)

Thromb Haemost 2014 111 5: 808-816


D. Kaudewitz (1), R. Lee (2), P. Willeit (1, 3), R. McGregor (1), H. S. Markus (4), S. Kiechl (5), A. Zampetaki (1), R. F. Storey (6), K. M. Channon (2), M. Mayr (1)

Thromb Haemost 2013 110 3: 609-615