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The Evolution of Antiplatelet Therapy After Percutaneous Coronary Interventions: A 40-Year Journey
Guillaume Marquis-Gravel1, Maxime Robert-Halabi1, Kevin R Bainey2
1Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
Insights
Antiplatelet therapy, including aspirin and P2Y12 inhibitors, is crucial for patients undergoing percutaneous coronary intervention (PCI). Ongoing research explores aspirin-free strategies and pre-PCI P2Y12 inhibitor use to optimize treatment.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Antiplatelet therapy is fundamental in managing patients after percutaneous coronary intervention (PCI).
- Landmark trials like the Canadian Aspirin trial and CURE established the efficacy of aspirin and clopidogrel (a P2Y12 inhibitor) in acute coronary syndromes and secondary prevention.
- Optimizing antiplatelet strategies for PCI patients remains an active area of research.
Purpose of the Study:
- To review major randomized trials that inform current practices for aspirin and P2Y12 inhibitor use in PCI.
- To highlight evolving areas of investigation, specifically aspirin-free strategies and the role of pre-PCI P2Y12 inhibitor administration.
- To identify unresolved questions in post-PCI antiplatelet management, including personalized dosing, intensity, formulation, duration, and treatment for high bleeding risk patients.
Main Methods:
- Systematic review of pivotal randomized controlled trials (RCTs) concerning antiplatelet therapy in PCI.
- Analysis of trial data focusing on clinical outcomes, particularly major adverse cardiovascular events and bleeding.
- Discussion of emerging research trends and areas lacking definitive guideline recommendations.
Main Results:
- Historical trials established aspirin and dual antiplatelet therapy (DAPT) with P2Y12 inhibitors as standard care post-PCI.
- Current research focuses on refining DAPT, exploring de-escalation, aspirin-free regimens, and the timing of P2Y12 inhibitor initiation.
- Significant questions persist regarding personalized antiplatelet therapy duration and management of high bleeding risk individuals.
Conclusions:
- Antiplatelet therapy remains central to PCI management, with aspirin and P2Y12 inhibitors forming the backbone of treatment.
- Aspirin-free strategies and pre-PCI P2Y12 inhibitor use represent critical areas for future guideline development.
- Personalizing antiplatelet therapy post-PCI based on individual risk profiles is essential for optimizing outcomes and minimizing bleeding complications.
Abstract:
Antiplatelet therapy has a critical role to play in the successful management of patients undergoing percutaneous coronary intervention (PCI). Over the past 40 years, a multitude of participants worldwide have been enrolled in trials evaluating the impact of antiplatelet agents on clinical outcomes. The use of aspirin in unstable angina in the Canadian Aspirin trial was key to establishing the benefit of aspirin in acute coronary syndrome. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial demonstrated that the P2Y12 inhibitor clopidogrel, when added to aspirin, reduced major cardiovascular events. While the use of antiplatelet agents in coronary artery disease antedates the introduction of PCI and remains the cornerstone of secondary prevention of atherosclerotic cardiovascular disease, strategies aiming to optimise their best use are still constantly evolving. In this review, the major randomised trials shaping current clinical practice for the use of aspirin and P2Y12 inhibitors in patients undergoing PCI are summarised, with a focus on aspirin-free strategies and on the role of P2Y12 inhibitor treatment before PCI, two major topics of ongoing investigation that are critical to patient care but that are not addressed in current practice guidelines. Multiple questions remain regarding the use of antiplatelet agents after PCI, including the personalisation of dosing, intensity, pharmacologic formulation, and duration of antiplatelet therapy based on individual patient characteristics and the optimal treatment of patients at high bleeding risk.
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