Pretreatment with P2Y12 inhibitors in ST-elevation myocardial infarction: Should we keep doing it?

de Cascais, Portugal Available online 14 October 2020 Dual antiplatelet therapy is an established and essential treatment in acute coronary syndrome (ACS) patients, with a class I recommendation in the European and American guidelines.Current practice in many centers still mandates an upfront loading dose with a P2Y 12 inhibitor as soon as possible, before percutaneous coronary intervention (PCI).However, the evidence is scarce and conflicting, and benefits from routine pretreatment before arrival at the cath lab remain uncertain.This is true for non-ST-elevation myocardial infarction and even more so for ST-elevation myocardial infarction (STEMI) patients. What is the rationale of pretreatment?One of the main arguments is biological plausibility.1 Since ACS most frequently results from occlusion of an artery by a platelet-rich thrombus, it is logical to assume that early administration of aspirin and a P2Y 12 inhibitor should provide greater benefit, enabling the highest level of platelet inhibition in the shortest possible time.For clopidogrel, still the most frequently used P2Y 12 inhibitor, its pharmacokinetic characteristics are relevant, given its very slow