Choice and timing of P2Y12 antiplatelet agents in non-STE acute coronary syndrome: A review

Saba Assar, David Louis, J. Dawn Abbott

Acute coronary syndromes remain a leading cause of morbidity and mortality worldwide. Reducing both ischemic and bleeding complications after percutaneous coronary intervention remains of paramount importance. The use of dual antiplatelet therapy (aspirin and a P2Y12 inhibitor) in the setting of acute coronary syndrome significantly reduces ischemic outcomes including cardiovascular death, recurrent myocardial infarction, and target vessel revascularization. Contemporary data suggests that the use of a high potency P2Y12 inhibitor (ticagrelor or prasugrel) with aspirin is superior to dual antiplatelet therapy using the low potency P2Y12 inhibitor clopidogrel. Furthermore, downstream administration of a P2Y12 inhibitor in the setting of unstable angina or non-ST elevation MI lowers the risk of bleeding without an increase in ischemic outcomes among patients undergoing an early invasive strategy. Additionally, for patients at high bleeding risk including those on oral anticoagulants, data supports shorter durations of dual antiplatelet therapy. In this review, the pathophysiology of acute coronary syndrome and latest evidence and guideline updates on P2Y12 antiplatelet therapy are summarized.