Evolving strategies in the management of acute coronary syndromes with oral antiplatelet agents

The treatment of acute coronary syndromes (ACS) is currently undergoing an interesting evolution due to the introduction of some novel antithrombotic drugs. The available evidence on new oral antiplatelet agents can be summarized as follows: (1) the new drugs (prasugrel and ticagrelor) are faster, more potent, and more predictable than clopidogrel, and thus prasugrel or ticagrelor may replace clopidogrel in most patients with ACS; (2) prasugrel seems to have a more pronounced acute effect, especially in patients with acute ST-elevation myocardial infarction (STEMI), and thus prasugrel may be the preferred drug for STEMI, especially for the acute phase; (3) ticagrelor seems to have better secondary preventive effects in the long term, which may be advantageous for patients with acute non-STEMI; and (4) both new drugs have some contraindications or unpleasant side effects and are both substantially more expensive, which may keep a place in therapy for clopidogrel for selected patients.