Pretreatment with P2Y12 inhibitors in non-ST-segment-elevation acute coronary syndrome is clinically justified.

Abstract

> My advice is to never do tomorrow what you can do today. Procrastination is the thief of time.1 > > Charles Dickens (1812–1870) The modulation of the P2Y12 receptor, carried out in the late 1990s with ticlopidine in patients with recent transient or focal cerebral or retinal ischemia2 or with clopidogrel in patients with recent ischemic stroke, myocardial infarction (MI), or symptomatic peripheral arterial disease3 resulted in a significant reduction in ischemic fatal or nonfatal end points compared with aspirin monotherapy. Response by Collet et al on p 1903 P2Y12 inhibitors have subsequently become the reference therapy in addition to aspirin for the prevention of acute and subacute stent thrombosis in patients undergoing coronary stent-based intervention. This dual-pathway antiplatelet therapy was shown to be more effective than aspirin alone and more effective and safer than aspirin and vitamin K antagonists.4–6 In this context, the achievement of more potent and consistent inhibition of the target receptor through prasugrel7 or ticagrelor8 has resulted in further improvements of the ischemic outcomes. Finally, clopidogrel9 and ticagrelor,8 but not prasugrel,7,10 have been shown to provide additional ischemic benefit on top of aspirin in patients with acute coronary syndromes, regardless of the final revascularization strategy. In light of the multiple chemical and pharmacological differences existing between the 3 currently available oral P2Y12 inhibitors, including potency,11 consistency and reversibility of the P2Y12 inhibition,12 binding site in the target receptor, and off-target effects,13,14 caution should be used in interpreting the value of these compounds as class effects. This concern is further corroborated by apparent discrepancies in study results noted throughout head-to-head comparisons.7,8 Because the clinical value of antithrombotic relies largely on the balance between ischemic …