P2Y12 inhibitors for acute coronary syndromes: current perspectives

Antiplatelet therapies are a cornerstone for the management of acute coronary syndromes (ACSs), based largely on the prominent role that platelet activation and aggregation has on the pathophysiology of the disease. Dual-antiplatelet therapy involving an oral P2Y 12 inhibitor plus aspirin is now considered standard of care for treating ACS. While clopidogrel has enjoyed nearly exclusive use as the P2Y 12 inhibitor of choice for many years, the more powerful P2Y 12 inhibitors prasugrel and ticagrelor have recently challenged clopidogrel as the preferred antiplatelet therapy for treating ACS. Both prasugrel and ticagrelor have proven to be superior to clopidogrel in reducing cardiovascular events in large clinical trials, albeit at the risk of increased bleeding. With the availability of these newer more potent agents, tailoring P2Y 12 inhibition to be more patient specific becomes an intriguing possibility. Factors such as type of ACS presentation, patient comorbidities, use of concomitant medications, platelet reactivity, genetic predisposition, and cost should all be considered. In addition to oral agents, intravenous P2Y 12 inhibition with cangrelor offers the advantage of quick onset and offset of action, but its clinical role is yet to be defined. Optimal medical and mechanical treatment of ACS hinges on suppressing platelet-related pathways, and P2Y 12 inhibition plays a key role. As our understanding of ACS continues to evolve, there remains much to learn with respect to optimizing the use of these powerful drugs to most effectively help achieve the best clinical outcomes.