Antiplatelet drugs in the treatment of acute coronary syndromes: Focus on cyclooxygenase inhibitors

Despite its widespread use and documented efficacy in the treatment of acut e coronary syndromes, aspirin has some limitations and the search for more effective and safer alternatives continues. This article analyses sonic cur rent aspects of the treatment of these syndromes with the cyclooxygenase in hibitor triflusal. Triflusal inhibits platelet cyclooxygenase activity but does not interfere significantly with endothelial synthesis of prostacyclin via the cyclooxyge nase-2 pathway. This drug also increases nitric oxide synthesis by neutroph ils, and decreases the activity of nuclear transcription factor NF-kappaB m ore than aspirin does. Moreover, triflusal inactivates intraplatelet phosph odiesterase and potentiates the antiaggregant effect of cAMP and cGMP, sinc e it interferes with the degradation of these compounds. These pharmacologi cal differences make triflusal potentially more effective and safer than as pirin. For unstable angina or non-Q-wave myocardial infarction, triflusal is as ef fective as aspirin. In a multicentre study of more than 2000 patients with acute myocardial infarction, triflusal was as effective as aspirin, and had a better safety profile, significantly decreasing (> 60%) the incidence of cerebrovascular accidents. The patients likely to benefit most from treatm ent with triflusal were those receiving fibrinolytic treatment, patients ol der than 65 years, and those receiving concomitant treatment with angiotens in-converting enzyme inhibitors. Triflusal is currently a valid alternative to aspirin for unstable angina, and for acute myocardial infarction it is the only alternative drug shown t o be as effective as aspirin but safer. (C) 2001 The European Society of Ca rdiology.