The nuances of new antiplatelet drugs in acute coronary syndrome

Platelets play an integral role in development of acute coronary syndrome (ACS) and thrombotic complications following Percutaneous Coronary Interventions (PCI). Aspirin and one of the P2Y12 receptor antagonist are mandatory for treatment of ACS and PCI. Aspirin is mandatory for all patients but there are three options in P2Y12 receptor antagonists (clopidogrel, prasugrel and ticagrelor). Prasugrel is approved for use in catheterization laboratory only and is the drug of choice for diabetics with ACS/STEMI/ stent thrombosis undergoing PCI. Ticagrelor produces better results compared to clopidogrel for medical treatment of ACS (N-STEMI and STEMI), medical treatment of recurrent ACS on clopidogrel and PCI of ACS in renal failure. Clopidogrel, the oldest P2Y12 receptor antagonist is currently utilized for medical treatment/PCI of ACS (N-STEMI and STEMI) particularly in subset of patients with high bleeding risk i.e. age > 70 years, body weight < 60 kg and history of TIA/stroke. Cangrelor failed to produce benefit in CHAMPION trials but was found useful in the BRIDGE trial for bridging patients on P2Y12 receptor antagonist for surgery. Vorapaxar was found useful in secondary prevention of atherothrombotic events in stable patients with a history of previous MI in the TRA 2°P-TIMI 50 trial but the benefit for treating patients with PAD was uncertain and the risk of ICH in patients with prior stroke was unacceptable. Elinogrel and aptamers are still investigational agents.