Aspirin remains the bedrock oral antiplatelet agent in patients with acute coronary syndrome (ACS). Dual-antiplatelet therapy is the standard of care in patients with ACS, particularly in patients undergoing percutaneous coronary intervention. Both of the new P2Y12 inhibitors-prasugrel-an irreversible, third-generation thienopyridine, and ticagrelor-a reversibly binding, direct acting agent, are associated with a faster onset of action, greater platelet inhibition and lower on-treatment platelet reactivity than clopidogrel and can over some of the limitations of clopidogrel therapy. These agents have been associated with improved clinical outcomes in two large ACS clinical trials; however, increased coronary artery bypass surgery coronary artery bypass surgery, and noncoronary artery bypass surgery related major bleeding were associated with prasugrel therapy and increased coronary artery bypass surgery-related bleeding was associated with ticagrelor. It may be cost effective to personalize antiplatelet therapy based on platelet function testing and/or genotyping to identify patients who are not responsive to clopidogrel. The pharmacological agents that directly block the binding of fibrinogen to GPIIb/IIIa receptor (GPIIb/IIIa inhibitors) are more effective in inhibiting platelet aggregation than any oral antiplatelet strategy. The use of the prasugel or ticagrelor, P2Y12 inhibitors with rapid onset of potent pharmacodynamic effects, may influence the future role of GPIIb/IIIa inhibitors in the treatment of the ACS patient. Direct thrombin inhibitors may have important role in the future pharmacologic management of patients with ACS. Bleeding is associated with worse clinical outcomes and optimal antithrombotic strategies to minimize its occurrence are mandatory in the care of the ACS patient.
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