OP-EHEA210720 3995..3999

This Focus Issue on thrombosis and antithrombotic treatment starts with the Special Article ‘Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy’ by Victor Aboyans from the University of Limoges in France, and colleagues. The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/ or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk (Figure 1). While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease (CAD), recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants is also discussed, based on a patient’s ischaemic and bleeding risk as well as therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide guidance on antithrombotic therapy according to arterial disease localizations and clinical presentation. It cannot, however, substitute for multidisciplinary team discussions, which are particularly important for patients with an uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of the utmost importance. Opioids remain the analgesic agent of choice in managing myocardial ischaemic pain. However, retrospective studies have raised concerns regarding potential interactions between opioids and oral P2Y12 inhibitors, which are a cornerstone of therapy in myocardial infarction. In an ESC Fast Track article entitled ‘Effects of lignocaine vs. opioids on antiplatelet activity of ticagrelor: the LOCAL trial’, Himawan Fernando from Monash University in Melbourne, Australia, and colleagues assessed the impact of intravenous fentanyl and lignocaine on the pharmacokinetics and pharmacodynamics of ticagrelor in patients with unstable angina and non-ST-segment elevation myocardial infarction and their procedural analgesic efficacy and safety. Seventy patients undergoing coronary angiography with ticagrelor loading were included in the pharmacokinetic and pharmacodynamic analyses of this randomized trial. Plasma ticagrelor levels 2 hours post-loading dose were significantly lower in the fentanyl arm than in the lignocaine treatment arm (598 vs. 1008 ng/mL, P = 0.014). The area under the plasma–time curves for ticagrelor (1228 vs. 2753 ng h/mL, P < 0.001) and its active metabolite (201 vs. 447 ng h/mL, P = 0.001) were both significantly lower in the fentanyl arm. Expression of activated platelet glycoprotein IIb/IIIa receptor and P-selectin was significantly higher at 60 min in the fentanyl arm. A higher proportion of patients had high on-treatment platelet reactivity in the fentanyl arm. The authors conclude that unlike fentanyl, lignocaine does not impair the bioavailability or delay the antiplatelet effect of ticagrelor. Both drugs were well tolerated and effective, with a high level of patient satisfaction for procedural analgesia. Routine procedural analgesia during percutaneous coronary intervention (PCI) should be