6. CLOPIDOGREL-
MOST WIDELY USED –causes irreversible alterations in
p2y12 receptor mediated platelet inhibition.
It has addictive effects when combined with aspirin due to
different mechanism of actions.
Now used commonly in ACS with aspirin.
Drawbacks- prodrug- delayed onset of action(4-6
hours),irreversible platelet inhibition (increased
hemmorhage)and has marked interindividual variability in
anti-platelet action called clopidogrel resistance( increased
stent thrombosis and MI)
Also has interaction with PPI , hence lead to reduced clinical
effects,PANTOPRAZOLE IS SAFE, because no interaction
with CYP2C19 cytochrome enzyme.
7. PRASUGREL
THEINOPYRIDINE group
Acts through P2Y12 receptor.
Prodrug- but acts more rapidly in 30 mins.
TRITOM-TIMI trial compared prasugrel and
clopidogrel in 13608 patients.All patients received
aspirin.
One group received Prasugrel 60 mg loading and
f/b 10 mg and other 300 mg clopi loading dose and
75 daily for 15 months.
Prasugrel had 24 % risk reduction.
8. BLEEDING risk is MORE.
HENCE NOT RECOMMENDED IN -
Elderly >75 years
< 60 kgs
History of previous strokes
Planned for urgent surgery.
Should only be given to patients whose coronary
anatomy is known after PCI, ONLY WHEN decision
to proceed to PTCA is made. NOT
RECOMMENDED FOR PATIENTS MANAGED
MEDICALLY.
9. TICAGRELOR-
NOVEL directly acting oral platelet p2y12 receptor
antagonist and REVERSIBLE ACTION.
FASTEST AND GREATER AND CONSISTENT anti-
platelet action.
PLATO Trial-compared ticagrelor and clopitab ,
decreased deaths and MI in the Ticagrelor group.
However NON-CABG and Intra-cranial bleeding higher.
Increased Dyspnea.
Increased Ventricular Phase of Holter Monitoring.
Recommended in ALL PATIENTS BEING MANAGED
COSERVATIVELY OR WITH INTERVENTIONS.
10. CANGRELOR-
Intravenous Platelet inhibitor.
Rapid onset and offset.
Reversible action and platelet function becomes
normal within 30- 60 minutes of stopping cangrelor.
Used in patient who need to undergo CABG,Sinc it
acts for less time with rapid offfset.
11. PROTEASE ACTIVATED RECEPTOR
1(PAR1) INHIBITORS-
Acts against THROMBIN induced Platelet
aggregation.
VORAPAXOR AND ATOPAXAR selective and
potent.
Reduces the risk of MI and death, but with
significant risk of bleeding.
12. GUIDELINES-
• Aspirin PLUS
• Clopitab, prasugrel or
ticagrelor
Acs with
planned
intervention
• Aspirin plus Clopidogrel
or ticagrelor
Medically
managed
ACS
• Aspirin plus clopidgrel
ELECTIVE
PCI
13.
14. UNSTABLE ANGINA OR NSTEMI
Aspirin
PLUS
BEFORE PCI- C/T/ OR IV GP 2B3A- Eptifibatide or
tirofiban
At the time of PCI-
Prasugrel /ticagrelor/clopidogrel or iv gp 2b3a
Without stenting-aspirin for lifelong and C OR T
upto 12 months.
15. ESC GUIDELINES-
Ticagrelor is recommended in all patients at
moderate to high risk ischaemic events (elevated
troponins ) irrespective of initial strategy.
Prasugrel only in whom coronary anatomy is known
proceeding to PTCA
Clopidogrel in all whom P OR T cant be given
16. STEMI
• Aspirin loading
• Plus clopidogrel 300 or prasugrel 60
or ticagrelor 180
Undergoing
Pami
• Aspirin plus clopidogrel 300 mg
loading if <75 years
Undergoing
Thrombolysising
• If pci performed within 24 hours
clopidogrel 300 mg loading and if
performed after 24hours- 600 mg
clopidogrel
Undergoing PCI
after
Thrombolysis
17. CLASS 1-
FOR ACS/NON STEMI /UA/ STEMI managed
medically-
Clopidogrel or ticagrelor- upto 12 months.
ACS undergoing PCI with stents-(bms or des)
clopidogrel or prasugrel or ticagrelor- upto 2- 3 years
ASPIRIN to be continued lifelong.
DURATION
18. CONCLUSION
NEWER anti-platelets like prasugrel and ticagrelor
have shown promising results better than
clopidogrel.
Other agents have shown reduction in clinical
events but increased risk of bleeding , hence still
under evaluation.
Not recmommended in cerebrovascular or other
peripheral vascular illnesses.
