Current evidence indicates that dual antiplatelet therapy with aspirin plus a P2Y12
inhibitor is essential for the prevention of thrombotic events after percutaneous
coronary interventions. However, dual antiplatelet therapy is associated with increased
bleeding which may outweigh the benefits. This has set the foundations for customizing
antiplatelet treatments to the individual patient. However, bleeding and ischemic
risks are often present in the same patient, making it difficult to achieve this balance.
The fact that oral P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) have
diverse pharmacodynamic profiles that affect clinical outcomes supports the rationale
for using platelet function and genetic testing to individualize antiplatelet treatment
regimens. Indeed, up to one-third of patients treated with clopidogrel, but a minority
of those treated with prasugrel or ticagrelor, exhibit high residual platelet reactivity
resulting in an increased thrombotic risk. On the other hand, prasugrel and ticagrelor
are frequently associated with low platelet reactivity and increased bleeding risk
compared with clopidogrel without providing any additional reduction in ischemic events
compared with patients who adequately respond to clopidogrel. The use of platelet
function and genetic testing may allow for a guided selection of oral P2Y12 inhibitors.
However, the nonuniform results of randomized controlled trials have led guidelines
to provide limited recommendations on the implementation of these tests in patients
undergoing percutaneous coronary intervention. In light of recent advancements in
the field, this consensus document by a panel of international experts fills in the
guideline gap by providing updates on the latest evidence in the field as well as
recommendations for clinical practice. (JACC Cardiovasc Interv. 2024;17:2639-2663)
(c) 2024 by the American College of Cardiology Foundation.
