P2Y12 inhibitors adjunctive to primary PCI therapy in STEMI: Fighting against the activated platelets

Primary percutaneous coronary intervention (PPCI) is the reperfusion method of choice in ST elevation myocardial infarction (STEMI). However, STEMI represents a highly pre-thrombotic state with platelets being greatly activated, so that an effective adjunctive to PPCI antiplatelet treatment with P2Y12 inhibitors is crucial in order to achieve an optimal reperfusion result. Clopidogrel has been extensively used in clinical practice, although it may not be the ideal agent for this condition due to its rather slow, weak and variable platelet inhibition action. Newer, more potent P2Y12 inhibitors like prasugrel and ticagrelor have been introduced recently and present a particularly favorable action profile for the highly prethrombotic milieu of STEMI. The efficacy and safety issues with the P2Y12 inhibitor use in STEMI and the possible role of phenotyping and/or genotyping for appropriate agent selection are discussed and several clinically important unanswered questions are raised.