Prasugrel

As cardiovascular disease remains the major cause of death in the United States, millions of Americans present to our hospitals with acute coronary syndromes. Recommendations for the use of thienopyridines are jointly agreed upon by the American College of Cardiology and the American Heart Association in their guidelines, in the setting of ST-segment elevation myocardial infarction (STEMI), non-STEMI, whether in the setting of percutaneous coronary intervention or not. The newly available thienopyridine prasugrel appears to be a promising advance in antiplatelet therapy with more potent antiplatelet effects and a lower incidence of interpatient variability in antiplatelet response than current options. Recent phase III data demonstrate that prasugrel is superior to clopidogrel in preventing cardiovascular morbidity and mortality in patients with acute coronary syndrome undergoing percutaneous coronary intervention, although with a greater risk of bleeding. As more becomes understood regarding clopidogrel resistance, concomitant use of proton pump inhibitors, pharmacogenomics, and the impending need for genomic assays in the near future, as with other anticoagulant therapies, appropriate patient selection for treatment with prasugrel can guarantee necessary benefit with an acceptable risk of bleeding.