Optimizing Platelet P2Y12 Inhibition for Patients Undergoing PCI

Guidelines recommend that dual antiplatelet therapy using aspirin and clopidogrel should be administered to the majority of patients with acute coronary syndromes, including those undergoing percutaneous coronary intervention (PCI). However, the results of a large randomized, placebo‐controlled study suggest that a 300‐mg loading dose of clopidogrel must be administered at least 15 h prior to PCI in order to achieve a significant reduction in peri‐PCI thrombotic events. Other data suggest that 2 h of pretreatment may be sufficient if a 600‐mg loading dose is used. Since it is often difficult to achieve an adequate pretreatment goal with clopidogrel in clinical practice, more rapid achievement of platelet P2Y₁₂ inhibition may improve patient outcomes. Prasugrel, [6‐[2‐(3,4‐diflurophenyl) cyclopropyl1‐1‐y1] amino‐2‐propylthio‐9?‐D‐ribofuranosyl‐9H‐purine (AZD6140), and cangrelor are platelet P2Y₁₂ receptor antagonists currently in development that offer faster acting inhibition of adenosine diphosphate (ADP)—induced platelet aggregation. These agents act upon the same platelet receptor as clopidogrel, but are distinguished by their routes of administration, reversibility, and pharmacodynamic properties. Prasugrel is an orally administered agent that provides faster, higher, and more consistent inhibition of platelet aggregation than clopidogrel. The results of Phase II testing suggest that the risk of bleeding is similar in prasugrel‐ and clopidogrel‐treated patients. AZD6140 is another orally administered platelet inhibitor with rapid and reversible action. Again, Phase II testing suggests similar bleeding risk for clopidogrel. Preliminary evidence suggests that clinical outcomes may be better in prasugrel‐ and AZD6140‐treated patients than in clopidogrel‐treated patients. Cangrelor is an intravenously administered, reversible, short‐acting agent with a rapid onset of activity. Bleeding risk and clinical outcomes data are similar in cangrelor‐ and abciximab‐treated patients. The results of ongoing Phase III clinical trials involving more than 40,000 patients will demonstrate whether these agents fulfill their potential to improve outcomes in PCI‐treated patients by providing faster, higher, and more consistent inhibition of platelet aggregation.