East Asian Paradox: Challenge for the Current Antiplatelet Strategy of One-Guideline-Fits-All Races in Acute Coronary Syndrome

Clinical experiences have suggested that East Asians show the higher risk of warfarin-related intracranial hemorrhage compared with Westerners. Therefore, different target of the International Normalized Ratio (INR) in East Asians (1.6-2.6) has been proposed and adapted in clinical practice. In terms with antiplatelet therapy, recent evidence has supported the concept of therapeutic level of platelet reactivity to balance clinical efficacy and safety in patients undergoing percutaneous coronary intervention (PCI) or those with acute coronary syndrome (ACS). In line with the warfarin experiences, multiple clinical and pharmacodynamic data from East Asians have shown their different therapeutic level of platelet reactivity following PCI or ACS (East Asian Paradox). Furthermore, like most cardiovascular drugs, P2Y(12) receptor blockers have marked interethnic differences in the pharmacokinetics and pharmacodynamics. The currently performed clinical trials evaluating the clinical efficacy and safety of potent P2Y(12) inhibitors mostly don't include enough number of East Asians to draw reliable conclusions. Therefore, dedicated research and guideline(s) for East Asians are required before we can apply Western recommendations for potent P2Y(12) inhibitors in East Asian population. It is a time to consider the paradigm shift from one-guideline-fits-all races to race-tailored antiplatelet therapy in treating ACS patients.