Unstable angina - Emerging treatments

Factor Xa inhibitors

These are being studied for acute coronary syndromes (ACS).[113] Rivaroxaban is a factor Xa inhibitor that has been shown to reduce cardiovascular events when given in addition to dual antiplatelet therapy to stabilised ST-elevation myocardial infarction (STEMI) patients, but increases bleeding events.[114] One review and meta-analysis found that direct oral anticoagulants in combination with antiplatelet therapy were associated with a reduced risk of ischaemic events at the cost of an increase in major bleedings compared with antiplatelet therapy alone in patients with STEMI.[115]

Factor IX inhibitors

Pegnivacogin, a factor IX inhibitor that is reversible with anivamersen, has been shown to reduce the incidence of ischaemic events in patients with ACS compared with intravenous heparin, when given during coronary interventions. This was in a phase 2 study that did not include patients with STEMI. A phase 3 trial including STEMI patients is currently under way.[116][117][118]

Factor XI inhibitors

Multiple factor XI inhibitors are under investigation for various indications.[119] Asundexian, a small molecule factor XIa inhibitor, has been investigated specifically for ACS.[119]

L-carnitine

One meta-analysis of 13 placebo-controlled trials found L-carnitine to significantly reduce all-cause mortality, ventricular arrhythmias, and angina symptoms in patients experiencing acute myocardial infarction (MI). Further evaluation is needed.[120]

Colchicine

Several randomised control trials have investigated the role of the anti-inflammatory agent colchicine in both chronic and acute coronary syndromes.[1][121] Use of colchicine for secondary prevention was shown to significantly reduce composite cardiovascular end points (including cardiovascular death, myocardial infarction, and stroke) in two meta-analyses of trials investigating patients with a previous acute coronary event.[121][122][123] Research suggests the beneficial effect is greater with early, in-hospital initiation of treatment.[124] Patients should be investigated for liver and/or kidney disease prior to commencing colchicine.[125] The European Society of Cardiology recommends that low-dose colchicine be considered for long-term management of patients with ACS on the basis of its anti-inflammatory properties, particularly if other risk factors are insufficiently controlled or recurrent cardiovascular events occur under optimal therapy.[1]

Dalcetrapib

Dalcetrapib, a cholesterol ester transfer protein (CETP) inhibitor, has been shown to reduce the incidence of new-onset diabetes in patients with recent ACS.[126]

Polypill therapy

One pill that combines routine post-ACS drugs (e.g., aspirin, an ACE inhibitor such as ramipril, and a statin such as atorvastatin) has been shown to improve treatment compliance and consequently reduce risk of adverse cardiovascular events post-ACS.[127]

Semaglutide

The glucagon-like peptide-1 (GLP-1) receptor agonist semaglutide has been shown to reduce the risk of death from cardiovascular causes in overweight patients with other cardiovascular risk factors.[128][129]