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Eur Heart J. 2016 Apr 21;37(16):1284-95. doi: 10.1093/eurheartj/ehv717. Epub 2015 Dec 27.

Pre-treatment with P2Y12 inhibitors in ACS patients: who, when, why, and which agent?

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Department of Cardiology, Ludwig-Maximilians-Universität München, Munich, Germany DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.
DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany Deutsches Herzzentrum München, Technische Universität München, Munich, Germany I. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
North Shore-Long Island Jewish Health System, Great Neck, NY, USA


Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12receptor inhibitor is the mainstay of treatment for acute coronary syndrome (ACS) patients, whether they undergo a percutaneous coronary intervention (PCI) or are managed medically. In recent years, the most appropriate timing for initiation and duration of P2Y12receptor inhibition has been a focus of great interest. Many observational studies and a single prospective trial (CREDO) utilizing clopidogrel had focused on whether pre-treatment with clopidogrel, i.e. its administration upstream of coronary angiography and PCI, is beneficial. Although the rationale for pre-treatment is obvious, large-scale randomized trials supporting a pre-treatment strategy with clopidogrel or with the newer P2Y12inhibitors prasugrel and ticagrelor did not exist. Proponents of a pre-treatment strategy had to rely on their best guess, on non-randomized studies, or on negative studies in which a trend for a benefit had been demonstrated. Recently, however, two randomized trials directly evaluated the value of pre-treatment-one in patients with a non-STE elevation myocardial infarction (NSTEMI)-the Comparison of Prasugrel at the Time of Percutaneous Coronary Intervention or as Pretreatment at the Time of Diagnosis in Patients with Non-ST Elevation Myocardial Infarction (ACCOAST) trial, and a second trial evaluating the use of ticagrelor in ST-elevation myocardial infarction (STEMI) patients, the Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST-elevation myocardial Infarction to open the Coronary artery (ATLANTIC) trial. Neither of the two trials, however, answered all the questions clinicians have about pre-treatment. And given the recent approval of the intravenous and rapidly acting P2Y12inhibitor cangrelor, the choice of who should receive treatment with a P2Y12inhibitor, which one should be used, and when it should be administered, should be carefully re-evaluated for all patients. This clinical review aims at evaluating the available evidence regarding the value of pre-treatment with the now four available oral and intravenous P2Y12inhibitors that can be administered to patients in whom coronary angiography followed by a possible PCI is planned.


Clopidogrel; Prasugrel; Pre-treatment; Ticagrelor

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