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A pharmacodynamic comparison of 5 anti-platelet protocols in patients with ST-elevation myocardial infarction
Sasha Koul1, Pontus Andell, Andreas Martinsson
1Department of Cardiology, Lund University, Skåne University Hospital Lund, SE 221 85, Lund, Sweden. sasha.koul@med.lu.se.
Insights
Switching to prasugrel after initial clopidogrel in ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI offers effective platelet inhibition. Ticagrelor also showed good response rates, unlike clopidogrel alone.
Area of Science:
- Cardiology
- Pharmacology
- Interventional Cardiology
Background:
- Early ischemic and bleeding events persist despite advances in anti-platelet therapy for ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI).
- Understanding platelet inhibition dynamics in the acute phase of myocardial infarction is crucial for optimizing anti-platelet strategies.
Purpose of the Study:
- To evaluate and compare the pharmacodynamic profiles of five different anti-platelet treatment strategies in STEMI patients during primary PCI.
- To assess platelet reactivity using vasodilator-stimulated phosphoprotein (VASP) assay.
Main Methods:
- Prospective inclusion of 223 STEMI patients undergoing primary PCI.
- Administration of five anti-platelet regimens: clopidogrel alone, clopidogrel followed by prasugrel switch, prasugrel alone, clopidogrel followed by ticagrelor switch, or ticagrelor alone.
- Serial measurement of platelet reactivity via vasodilator-stimulated phosphoprotein (VASP) assay.
Main Results:
- Patients switching from clopidogrel to prasugrel or receiving prasugrel alone demonstrated >90% good responders the day after PCI.
- Prasugrel achieved a VASP value <50% within 1.5 hours of administration.
- Pre-hospital ticagrelor resulted in 50% good responders by PCI completion, with an average time to VASP <50% of 2.3 hours.
- Clopidogrel monotherapy showed only 32% good responders post-PCI.
Conclusions:
- Switching from an initial clopidogrel dose to prasugrel during primary PCI is safe, feasible, and provides potent platelet inhibition.
- Pre-hospital ticagrelor administration offers a 50% good responder rate at PCI completion.
- Clopidogrel monotherapy demonstrates suboptimal platelet inhibition in the acute phase of STEMI.
Background:
Despite advances in anti-platelet treatments, there still exists an early increase in both ischemic as well as bleeding events following primary PCI in patients with ST-elevation myocardial infarction (STEMI). Platelet inhibition data of different anti-platelet treatments in the acute phase of a myocardial infarction might offer some insight into these problems. The aim of this study was to evaluate the pharmacodynamic profile of 5 different anti-platelet treatments in the acute phase of STEMI in patients undergoing primary PCI.
Methods:
A total of 223 STEMI patients undergoing primary PCI were prospectively included. Patients received either pre-hospital clopidogrel only, pre-hospital clopidogrel followed by prasugrel switch in the cath lab, prasugrel treatment only, pre-hospital clopidogrel followed by ticagrelor switch in the cath lab or pre-hospital ticagrelor only. Platelet reactivity was measured serially using vasodilator-stimulated phosphoprotein (VASP).
Results:
Patients receiving pre-hospital clopidogrel followed by prasugrel switch showed similar platelet inhibition data as patients receiving prasugrel only, with more than 90% being good responders the day after PCI. Average time from prasugrel administration to a VASP value of <50% was 1.5 hours. In patients receiving pre-hospital ticagrelor, 50% were good responders at completion of PCI and average time to a VASP-value of <50% was 2.3 hours. Only 32% of patients receiving clopidogrel only were responders the day after PCI.
Conclusions:
Switching from an upstream bolus dose of clopidogrel to prasugrel at the time of PCI, appeared as a safe and feasible option with no tendency for overshoot or attenuation of platelet inhibition. Pre-hospital administration of ticagrelor was associated with a 50% good responder rate at completion of PCI.
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