Should I give aspirin and a P2Y12 inhibitor, such as clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta), prior to percutaneous coronary intervention (PCI) in a patient with ST-elevation myocardial infarction (STEMI)?

From the Guidelines

You should give both aspirin and a P2Y12 inhibitor prior to percutaneous coronary intervention (PCI) in a patient with ST-elevation myocardial infarction (STEMI). For aspirin, give a loading dose of 162-325 mg chewed immediately. For the P2Y12 inhibitor, options include clopidogrel (600 mg loading dose), prasugrel (60 mg loading dose, avoid in patients ≥75 years old or <60 kg or with prior stroke/TIA), or ticagrelor (180 mg loading dose) 1. These medications should be given as soon as possible after STEMI diagnosis, ideally in the emergency department or even pre-hospital setting if available. This dual antiplatelet therapy (DAPT) is crucial because it inhibits platelet aggregation through complementary mechanisms - aspirin blocks the cyclooxygenase pathway while P2Y12 inhibitors block ADP-mediated platelet activation. Early administration helps prevent thrombotic complications during and after PCI by reducing the risk of stent thrombosis and recurrent ischemic events. After PCI, DAPT should be continued with aspirin 81 mg daily indefinitely and a P2Y12 inhibitor (typically for at least 12 months) 1. It's also important to consider the patient's renal function when selecting a P2Y12 inhibitor, as some may require dose adjustments in patients with renal impairment 1. Additionally, the choice of P2Y12 inhibitor may depend on the patient's individual risk factors, such as prior stroke or TIA, and the potential for bleeding complications 1. Overall, the administration of aspirin and a P2Y12 inhibitor prior to PCI in STEMI patients is a critical component of evidence-based practice, supported by guidelines from the American College of Cardiology and American Heart Association 1.

From the FDA Drug Label

Prasugrel tablets are a P2Y12 platelet inhibitor indicated for the reduction of thrombotic cardiovascular events (including stent thrombosis) in patients with acute coronary syndrome who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina or non-ST-elevation myocardial infarction (NSTEMI) (1.1). Patients with ST-elevation myocardial infarction (STEMI) when managed with either primary or delayed PCI (1.1). Clopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization Clopidogrel tablets are indicated to reduce the rate of myocardial infarction and stroke in patients with acute ST-elevation myocardial infarction (STEMI) who are to be managed medically.

Key Points:

• Aspirin and a P2Y12 inhibitor should be given to patients with STEMI who are to be managed with PCI.
• Prasugrel is indicated for patients with STEMI when managed with either primary or delayed PCI.
• Clopidogrel is indicated to reduce the rate of myocardial infarction and stroke in patients with acute STEMI who are to be managed medically, and should be administered in conjunction with aspirin.
• It is recommended to initiate clopidogrel with a single 300 mg oral loading dose and then continue at 75 mg once daily in patients who need an antiplatelet effect within hours 2.
• Prasugrel and clopidogrel are both P2Y12 inhibitors that increase the risk of bleeding, and the risk factors for bleeding include concomitant use of other drugs that increase the risk of bleeding 3, 2.

From the Research

Administration of DAPT or SAPT Prior to PCI in STEMI

• The standard of care for patients undergoing percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) includes dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor 4.
• DAPT reduces rates of ischemic events in patients with STEMI, and the optimal strategy for P2Y12 administration in STEMI patients is still evolving 4.
• Oral ticagrelor/prasugrel given before or immediately after STEMI PCI is usually sufficient to prevent thrombotic complications 4.

Choice of P2Y12 Inhibitor

• Prasugrel and ticagrelor provide a more prompt, potent, and predictable antiplatelet effect compared with clopidogrel, which translates into better clinical outcomes 5.
• Cangrelor is an intravenous P2Y12 receptor antagonist with a short half-life and rapid cessation of its effect after discontinuation, which can be used in patients presenting with STEMI as one of the two anti-platelet agents along with aspirin 6.

Timing of Administration

• Pretreatment with dual antiplatelet therapy, including a P2Y12 inhibitor, was associated with better pre-PCI coronary perfusion, lower incidence of definite stent thrombosis, cardiogenic shock, and, possibly, all-cause mortality with no sign of potential harm encountered 7.
• Strategies of increased ticagrelor/prasugrel loading dose or earlier administration in STEMI have not been successful in closing the platelet inhibition gap 4.

Safety and Efficacy

• Prasugrel had the most favorable trend for ischemic outcomes, including myocardial infarction (MI), stroke, and revascularization, although none of these trends was statistically significant due to lack of power for each outcome 8.
• Pretreatment was not associated with a higher risk of major bleeding events 7.