The future of antiplatelet therapy: optimizing management in patients with acute coronary syndrome

In the past few years, the antiplatelet armamentarium has been markedly enriched. With the intravenous platelet glycoprotein IIb/IIIa inhibitors and the new thienopyridine clopidogrel, the options for acute and chronic antiplatelet therapy have expanded. Future therapies will optimize the application of these agents. For example, in percutaneous coronary intervention, it appears that patients may benefit by loading with an adenosine diphosphate receptor blocker before the procedure and may well benefit indefinitely from continuation of this therapy. Patients with aspirin resistance or the P1A2 single nucleotide polymorphism that is common in the population may derive particular benefit from dual antiplatelet therapy. Similarly, patients who present with unstable angina while receiving chronic aspirin therapy and those with involvement of more than one atherosclerotic bed deserve consideration for dual antiplatelet therapy. New applications will be facilitated by point-of-care testing for platelet biology and genotyping, pharmacogenomics, and protection from inflammation in patients with serologic evidence of elevated markers, such as C-reactive protein. Indeed, even with the recent explosion of relevant data and enriched therapeutic choices, we are just beginning to understand the optimal application of these therapies to the appropriate clinical indications and patient groups.