Unstable angina - Emerging treatments

Factor IX inhibitors

Pegnivacogin, a factor IX inhibitor that is reversible with anivamersen, has been shown to reduce the incidence of ischemic events in patients with acute coronary syndrome (ACS) compared with intravenous heparin, when given during coronary interventions. This was in a phase 2 study that did not include patients with ST-elevation myocardial infarction (STEMI). One phase 3 trial including STEMI patients is currently underway.[137][138][139]

Factor XI inhibitors

Multiple factor XI inhibitors are under investigation for various indications.[140] Asundexian, a small molecule factor XIa inhibitor, has been investigated specifically for ACS.[140]

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.[141]

Bone marrow stem-cell therapy

Stem-cell therapy has been proposed as a potential therapy for the repair and regeneration of damaged vascular and cardiac tissue following an acute MI. Although current evidence suggests that stem-cell therapy is safe, its effect on mortality, quality of life, and myocardial function following an acute MI is unclear.[142] This is based, however, on limited evidence from small clinical trials. One randomized controlled study found intracoronary bone marrow cell therapy to be safe, but its effect on myocardial function and myocardial salvage was unclear.[143]

Colchicine

Several randomized control trials have investigated the role of the anti-inflammatory agent colchicine in both chronic and ACS.[1][144] Use of colchicine for secondary prevention was shown to significantly reduce composite cardiovascular end points (including cardiovascular death, MI, and stroke) in two meta-analyses of trials investigating patients with a previous acute coronary event.[144][145][146] Research suggests the beneficial effect is greater with early, in-hospital initiation of treatment.[147] Patients should be investigated for liver and/or kidney disease prior to commencing colchicine.[148] 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.[149]

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.[150]

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.[151][152]

Vorapaxar

Vorapaxar is an oral competitive protease-activated receptor-1 antagonist that inhibits thrombin-induced platelet aggregation. In patients with ACS, the addition of vorapaxar to standard therapy did not significantly reduce the primary end point, but significantly increased the risk of major bleeding including intracranial hemorrhage.[153]