The Use Pattern and Clinical Impact of Novel P2Y12 Receptor Antagonists for Acute Myocardial Infarction in Korea

Dual antiplatelet treatment (DAPT) with aspirin and a P2Y12 receptor antagonist is essential for patients presenting with acute coronary syndrome (ACS) irrespective of their specific percutaneous coronary intervention (PCI). Clopidogrel (Bristol-Myers Squibb/Sanofi Pharmaceuticals, Bridgewater, NJ, USA), one of the most popular P2Y12 receptor antagonists of the past decade, has reduced the risk of cardiovascular (CV) death, myocardial infarction (MI), and stroke in patients with ACS by 20–30% when added to aspirin.1) However, it has some limitations, including modest inhibition of platelet activity, delayed onset and offset of action, and inter-individual variability of pharmacodynamic responses. To overcome these drawbacks, 2 novel P2Y12 receptor antagonists, prasugrel (Eli Lilly and Company, Indianapolis, IN, USA) and ticagrelor (AstraZeneca Pharmaceuticals LP, Wilmington, DE, USA), have been developed and have demonstrated promising results. The TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet inhibitioN with Prasugrel Thrombolysis In Myocardial Infarction 38 (TRITON-TIMI 38) trial found that prasugrel could reduce the composite risk of CV death, MI, or stroke in moderate-to-high-risk ACS patients undergoing PCI by 19% at the cost of higher risk of bleeding, including lifethreatening hemorrhage, compared with clopidogrel.2) Unfortunately, the use of prasugrel did not decrease CV death or overall mortality and has limitations of use in specific groups, such as elderly people (>75 years of age), patients with prior history of stroke, those with low body weight (<60 kg), or patients not concurrently receiving PCI. Ticagrelor has also shown to decrease the composite risk of CV death, MI, or stroke by 16% and the risk of CV death by 21% in ACS patients, irrespective of treatment strategy, compared with clopidogrel.3) Despite increases in both major and minor bleeding, ticagrelor did not lead to any increase in fatal bleeding. With the advent of these novel P2Y12 receptor antagonists, the combination of aspirin and prasugrel or ticagrelor instead of clopidogrel as a DAPT has been increasingly used. Contemporary guidelines recommend the use of prasugrel or ticagrelor in the setting of acute myocardial infarction (AMI).4) A few epidemiological studies from several countries have shown that the use of these novel P2Y12 receptor antagonists is rapidly increasing and has reduced the incidence of CV events or death in ACS patients compared with clopidogrel. A Danish nationwide population-based cohort study involving 28,449 patients demonstrated that the use of clopidogrel as a DAPT after AMI in 2009 had been reduced in favor of ticagrelor or prasugrel in 2012.5) The Melbourne Interventional Korean Circ J. 2017 Nov;47(6):864-867 https://doi.org/10.4070/kcj.2017.0302 pISSN 1738-5520·eISSN 1738-5555