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Antiplatelet drug 'resistance'. Part 2: laboratory resistance to antiplatelet drugs—fact or artifact?

Nature Reviews Cardiology volume 6, pages 365–373 (2009)Cite this article

Abstract

Many patients experience recurrent ischemic events despite optimal antiplatelet therapy. This has generated much interest in finding a laboratory test of platelet function to identify such patients, who have been termed 'nonresponders' or antiplatelet 'resistant'. Laboratory tests of platelet function have identified 'resistance' in 5–60% of patients taking aspirin and 4–30% of those taking clopidogrel. However, these tests of 'resistance' have not correlated closely with subsequent recurrent events, and have not reliably identified nonresponders to antiplatelet therapy. Here, we identify and discuss three major limitations common to all these tests. Firstly, they are performed on citrate-anticoagulated blood, secondly, blood is stored for a variable period of time, and thirdly, the assessment of thrombotic status on the basis of platelet response to only one or two agonists ignores the complexity of the mechanism of platelet thrombus formation in vivo. In this Review we discuss the significance of these important limitations, and the applicability of such in vitro platelet function tests to the prediction of in vivo events. We conclude that such tests are so unphysiological that they cannot reliably predict the true thrombotic status of patients. Identification of 'resistance' on the basis of these tests lacks sensitivity and specificity for identifying thrombotic risk, and is likely to be artifactual.

Key Points

  • We believe that the true thrombotic status of patients cannot be assessed using currently available in vitro tests and, therefore, the existence of 'resistance' to antiplatelet therapy is questionable

  • Most data on 'resistance' to antiplatelet drugs are provided by platelet aggregometry, modified thromboelastography, the platelet function analyzer 100 (PFA-100)®a and VerifyNow®b assays

  • With the exception of thrombin, physiological platelet stimuli do not cause secondary aggregation, granule release and thromboxane A2 generation in native blood

  • The use of citrated blood with critically low Ca2+ distorts the in vivo effect of platelet agonists and antagonists

  • None of the currently available in vitro tests of platelet function allow the assessment of thrombin generation by activated platelets

aDade international, Inc., Deerfield, IL.

bAccumetrics, Inc., San Diego, CA.

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Figure 1: Schematic demonstrating the key role of calcium in platelet reactivity.

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Authors and Affiliations

  1. National Heart and Lung Institute, Imperial College, London, UK

    Diana A. Gorog

  2. Mount Sinai Medical Center, New York, NY, USA

    Joseph M. Sweeny

  3. Mount Sinai School of Medicine, New York, NY, USA

    Valentin Fuster

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  1. Diana A. Gorog
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Correspondence to Diana A. Gorog.

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Gorog, D., Sweeny, J. & Fuster, V. Antiplatelet drug 'resistance'. Part 2: laboratory resistance to antiplatelet drugs—fact or artifact?. Nat Rev Cardiol 6, 365–373 (2009). https://doi.org/10.1038/nrcardio.2009.13

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