From the Guidelines
Ticagrelor is the most effective P2Y12 inhibitor for patients with acute coronary syndrome, due to its potent and consistent platelet inhibition, as evidenced by the 2021 European Heart Journal study 1. The choice of P2Y12 inhibitor depends on the specific clinical situation, including the patient's bleeding risk, comorbidities, and concomitant medications.
- Ticagrelor (Brilinta) is typically dosed at 180mg loading dose followed by 90mg twice daily, and is recommended for patients with ACS, regardless of initial treatment strategy, unless there are contraindications 1.
- Prasugrel (Effient) is another potent option, given as a 60mg loading dose followed by 10mg daily, but is contraindicated in patients with prior stroke/TIA, age >75, or weight <60kg.
- Clopidogrel (Plavix), while less potent, remains useful in certain scenarios at 300-600mg loading dose followed by 75mg daily, particularly for patients who cannot tolerate the stronger agents or have lower bleeding risk profiles. The 2021 European Heart Journal study 1 provides the most recent and highest quality evidence, and recommends ticagrelor as the preferred P2Y12 receptor inhibitor for NSTE-ACS patients who proceed to PCI, due to its rapid onset of action and more consistent platelet inhibition.
- The study also notes that prasugrel may be considered the preferred P2Y12 receptor inhibitor for NSTE-ACS patients who proceed to PCI, due to its possible benefit in improving endothelial function.
- However, the choice between ticagrelor and prasugrel should be individualized based on the patient's specific clinical situation and risk factors.
From the Research
P2Y12 Inhibitors
- P2Y12 inhibitors are a class of antiplatelet drugs used to prevent thrombotic events in patients with acute coronary syndromes (ACS) 2, 3, 4, 5, 6
Comparison of P2Y12 Inhibitors
- Ticagrelor is a potent, oral P2Y12 inhibitor that may be preferred over other P2Y12 inhibitors in certain patient populations, such as those with diabetes, a history of stroke or transient ischemic attack, and chronic kidney disease 2
- A guided approach to selecting P2Y12 inhibiting therapy, using platelet function or genetic testing, may be associated with reduced major adverse cardiovascular events without a significant increase in bleeding 3
- Prasugrel and ticagrelor have been shown to be more effective than clopidogrel in reducing ischemic events, but may also increase the risk of bleeding 3, 4
Ticagrelor
- Ticagrelor is a first-generation, reversible P2Y12 inhibitor that has been shown to be more efficacious than clopidogrel in the treatment of patients with ACS 5, 6
- Ticagrelor has a rapid onset of action and a consistent antiplatelet effect, making it a promising candidate for a first-choice antiplatelet agent in patients with acute coronary events 5
- Ticagrelor may be associated with a higher risk of bleeding and dyspnea compared to clopidogrel, but its benefits may outweigh these risks in certain patient populations 2, 5