From the Guidelines
For patients with Wellens syndrome, the optimal treatment approach involves both dual antiplatelet therapy (DAPT) with ticagrelor and aspirin, and urgent percutaneous coronary intervention (PCI), rather than choosing between them. The management of Wellens syndrome, which indicates critical proximal LAD stenosis with a high risk of extensive anterior myocardial infarction, requires urgent cardiac catheterization and likely PCI 1. While awaiting catheterization, patients should receive loading doses of dual antiplatelet therapy:
- ticagrelor 180 mg followed by 90 mg twice daily,
- plus aspirin 325 mg loading dose followed by 81 mg daily, as recommended by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. After PCI, DAPT should be continued with ticagrelor 90 mg twice daily and aspirin 81 mg daily for at least 12 months in most cases. This approach is necessary because Wellens syndrome represents unstable coronary disease requiring both immediate pharmacological platelet inhibition and mechanical intervention to restore coronary flow. Ticagrelor is preferred over clopidogrel in this acute coronary syndrome setting due to its more rapid onset and more potent platelet inhibition, as supported by the 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease 1. Medical therapy alone without PCI is insufficient for Wellens syndrome due to the high risk of progression to extensive anterior wall myocardial infarction. Key points to consider in the management of Wellens syndrome include:
- Urgent initiation of dual antiplatelet therapy with ticagrelor and aspirin
- Prompt referral for cardiac catheterization and PCI
- Continuation of DAPT for at least 12 months post-PCI
- Preference for ticagrelor over clopidogrel due to its pharmacological properties.
From the Research
Optimal Treatment for Wellens Syndrome
The optimal treatment for Wellens syndrome is a topic of ongoing research and debate.
- Dual Antiplatelet Therapy (DAPT): DAPT, consisting of aspirin and a P2Y12 inhibitor (such as ticagrelor), is a common treatment approach for acute coronary syndrome (ACS) and has been shown to reduce cardiovascular event rates 2.
- Percutaneous Coronary Intervention (PCI): PCI is a procedure used to open narrowed or blocked coronary arteries, and is often performed in conjunction with DAPT 3.
- Ticagrelor and Aspirin vs. PCI: The choice between ticagrelor and aspirin versus PCI depends on various factors, including the patient's risk of bleeding and ischemic events 4, 5, 6.
- Bleeding Risk: Patients at high risk of bleeding may benefit from de-escalation of DAPT or the use of ticagrelor monotherapy after a minimum period of dual antiplatelet therapy 5, 6.
- Ischemic Risk: Patients at high risk of ischemic events may benefit from continued use of DAPT, including aspirin and a P2Y12 inhibitor 2, 3.
Key Findings
- A study published in JAMA found that DAPT reduces cardiovascular event rates after ACS, but the optimal duration of DAPT is not well established 2.
- A systematic review and network meta-analysis published in BMJ evidence-based medicine found that DAPT de-escalation may reduce the risk of bleeding events compared to continued use of aspirin and a P2Y12 inhibitor 4.
- A post hoc analysis of the GLOBAL LEADERS trial published in JAMA cardiology found that aspirin was associated with increased bleeding risk and did not add to the benefit of ticagrelor on ischemic events between 1 month and 12 months after PCI in patients with ACS 5.
- A double-blind trial published in The New England journal of medicine found that ticagrelor monotherapy was associated with a lower incidence of clinically relevant bleeding than ticagrelor plus aspirin, with no higher risk of death, myocardial infarction, or stroke, among high-risk patients who underwent PCI and completed 3 months of dual antiplatelet therapy 6.