Antiplatelet therapy in percutaneous coronary intervention: integration of prasugrel into clinical practice

Antiplatelet therapy is one of the key initial therapeutic interventions to prevent thrombotic complications associated with percutaneous coronary intervention. Aspirin and the thienopyridines, clopidogrel, and ticlopidine, are the most widely used oral antiplatelet agents in patients with non-ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention. Recent data have demonstrated limitations with the currently approved dosing regimen of clopidogrel (loading dose, 300 mg; maintenance dose, 75 mg daily) in a significant number of patients during the first few hours-days of treatment (Gurbel et al, Circulation. 2003;107:2908-2913 and Lau et al, Circulation. 2004;109:166-171). To circumvent this problem, some centers use a higher loading dose of clopidogrel (600 mg). Prasugrel is a novel thienopyridine prodrug similar to clopidogrel and ticlopidine that is more efficiently metabolized to its active metabolite compared with the 2 older drugs, providing enhanced platelet inhibition with less intersubject variability. The Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis In Myocardial Infarction 38 (TRITON-TIMI 38) study was a phase 3, multicenter trial that studied prasugrel in comparison with Clopidogrel in patients with moderate-to-high-risk acute coronary syndromes. In this article, we discuss the findings of this major trial, review previously published literature that compares the 2 medications, and provide a clinical context for the potential role of prasugrel in practice.