Strategies to optimize initial P2Y₁₂ inhibitor therapy in STEMI patients

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y₁₂ inhibitor is the standard of care for patients who undergo percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI). Though this regimen reduces rates of ischemic events in patients with STEMI, the optimal strategy for P2Y₁₂ administration in STEMI patients is still evolving.

The purpose of this review is to summarize current evidence on optimal use of ticagrelor and prasugrel in the acute phase of STEMI.

Due to high platelet activity in the acute setting of STEMI and PCI, adequate and rapid platelet inhibition is important. Strategies of increased ticagrelor/prasugrel loading dose or earlier administration in STEMI have not been successful in closing this platelet inhibition gap. Potential strategies for improving ticagrelor/prasugrel use early in STEMI include bridging with intravenous antiplatelet agents or crushed or chewed administration.

Oral ticagrelor/prasugrel given before or immediately after STEMI PCI is usually sufficient to prevent thrombotic complications. When faster platelet inhibition is desired, or oral administration is compromised by inability to swallow tablets, crushing/chewing ticagrelor/prasugrel tablets is an alternative to intravenous P2Y₁₂ inhibitor therapy.