Potent P2Y12 Inhibitors in Low Risk Patients : Is There a Medical Need ?

The oral P2Y12 inhibitors prasugrel and ticagrelor have demonstrated biological and clinical superiority over clopidogrel, with a faster onset of action and greater potency, which translate into improved clinical outcomes in patients with acute coronary syndrome (ACS). They have very similar pharmacodynamics, and fit the need for expedited mechanical reperfusion in patients presenting with a partially occlusive thrombus in non−ST-segment elevation myocardial infarction (NSTEMI) or with a fully occlusive thrombus in ST-segment elevation myocardial infarction (STEMI). Whether these drugs are useful when there is no thrombus, no myocardial infarction (MI), and no emergency in patients presenting for a scheduled percutaneous coronary intervention (PCI), is unknown. Benefits observed with prasugrel and ticagrelor on stent thrombosis, major adverse cardiovascular events, and even mortality in ACS patients may not be found in lower-risk populations. Similarly, the latest European Society of Cardiology guidelines recommend ticagrelor in moderate- to high-risk ACS patients (e.g., with elevated troponin), and a post hoc analysis of the PLATO (Platelet Inhibition and Patient Outcomes) study suggested little, if any, benefit in troponin-negative patients. European guidelines for stable coronary artery disease (CAD) consistently recommend clopidogrel only for coronary stenting in stable patients, and advise no pretreatment before a patient’s coronary status and indication for revascularization are known.