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Is Antiplatelet Resistance a Potential Risk Factor? C.Richard Conti M.D. MACC Is Aspirin resistance a Risk Factor? Aspirin is an effective antiplatelet agent with proven benefit for the prevention of atherothrombotic complications of CV disease However,Many patients taking aspirin have cardiac events Aspirin resistance is estimated anywhere between 5% and 40% Aspirin is cardioprotective In a meta-analysis of patients with high risk peripheral vascular disease; ASA therapy was associated with a 34% risk reduction in Non fatal MI 25% risk reduction in non fatal stroke 18% reduction in all cause mortality *BMJ 2002,324:71-86 Aspirin Resistance: A confusing Term not well defined ! TIMI Risk score Compliance “allergy”-GI intolerance True allergy Malabsorbtion Inadequate dose Smoking Increased catecholamine levels True functional resistance Why are patients aspirin resistant Clinical Variables Cigarettes NSAID’s Sub therapeutic doses of ASA Biologic Variables Alternate pathways of platelet activation Genetic Variables Mutations of the COX-1 gene What is the best way to detect Aspirin Resistance? There is no “one” good way to assess platelet function. The clinical relevance of “Aspirin Resistance” as determined by current laboratory methods is uncertain. How can aspirin resistance be detected Bedside point of care measurement of Platelet Function PFA 100(platelet function analyser)* RPFA (rapid platelet function assay)** * Dade-Behring, Deerfield, IL ** Accumetrics, San Diego,CA Selected Studies of Aspirin Resistance #/pts ASA dose Method Prevalence(%) 72/SAP 160 PFA 100 * 29.2 129/SAP 160 PFA 100 ** 1.35 422/SAP 325 RPFA*** 23.0 151/PCI 80-325 RPFA*** 19.2 *epi closure time 186 sec ** epi closure time 196 sec ***Aspirin resistance units (ARU)550 What Can be done about Aspirin resistance? Increase dose and repeat aggregation test If still resistant Switch to clopidogrel Treat ACS, HF, BMI, Insulin resistance, hyperglycemia, hypercholesterolem