Importance of potent P2Y(12) receptor blockade in acute myocardial infarction: focus on  prasugrel.
BACKGROUND
Prasugrel therapy is recommended in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI).


METHODS
This article reviews the efficacy and safety profile of prasugrel, cost considerations, and its role in clinical practice based on published data. The authors searched PubMed and Ovid databases for English language clinical trial articles involving the use of prasugrel in human subjects and patients, published through June 2012. The keyword "prasugrel" was used. The review focuses on clinical trials, but other articles including Food and Drug Administration documents are also reviewed.


CONCLUSIONS
Prasugrel has a more rapid and greater pharmacodynamic (PD) effect than clopidogrel. No significant drug - drug interactions have been reported. In a large-scale randomized clinical trial, prasugrel was associated with better protection against ischemic event occurrence compared to clopidogrel, but more bleeding in ACS patients undergoing PCI. Adverse outcomes outweighed the benefit of prasugrel in certain subgroups, including patients over the age of 75, those weighing less than 60 kg, and patients with a prior history of stroke or transient ischemic attack. In subsequent PD studies, prasugrel therapy showed suboptimal platelet inhibition in selected patients. In addition, "hyper-responsiveness" to prasugrel may increase the risk of serious bleeding in high-risk patients. More detailed studies are warranted to explore antiplatelet regimens tailored to optimally limit ischemic and bleeding event occurrences. A Phase-III TRILOGY trial (NCT00699998) will indicate the clinical efficacy and safety of prasugrel in patients with non-ST-segment elevation ACS, who are medically managed without coronary revascularization.
Sinai Center for Thrombosis Research, Cardiac Catherization Laboratories, 2401 W. Belvedere Ave, Baltimore, MD 21215, USA.
Young-Hoon
YH
Jeong
Udaya S
US
Tantry
Paul A
PA
Gurbel
D000077144:Clopidogrel; D003365:Costs and Cost Analysis; D004347:Drug Interactions; D006801:Humans; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000191:economics; D010879:Piperazines / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use*; D000068799:Prasugrel Hydrochloride; D058921:Purinergic P2Y Receptor Antagonists / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use*; D058925:Receptors, Purinergic P2Y12 / Q000378:metabolism; D013876:Thiophenes / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use*; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000191:economics / Q000493:pharmacokinetics / Q000627:therapeutic use
C548576:P2RY12 protein, human; D010879:Piperazines; D058921:Purinergic P2Y Receptor Antagonists; D058925:Receptors, Purinergic P2Y12; D013876:Thiophenes; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine