Dual antiplatelet
therapy (
DAPT), usually consisting of
clopidogrel and
acetylsalicylic acid (ASA), has come into discussion in recent years due to an increasing number of
major adverse cardiac events based on insufficient
ADP-mediated platelet inhibition with
clopidogrel, mainly explained by drug interactions or genetic variants slowing or hindering the bioactivation of the
prodrug clopidgrel into an active metabolite. Accordingly, new
antiplatelet agents like
prasugrel and
ticagrelor were investigated in large prospective randomized clinical trials in patients with different entities of
acute coronary syndromes (ACS). Based on their beneficial results in comparison to
clopidogrel, these agents have found their way into the recent international guidelines for treatment of patients with
acute coronary syndromes. Both
antiplatelet agents demonstrated superiority with respect to the primary composite endpoint (cardiovascular death/non-lethal
myocardial infarction/
stroke).
Ticagrelor even exhibited a mortality benefit over the comparator, but both compounds also increased the risk of spontaneous major bleedings to a significant extent. However, the efficacy/safety ratio of
prasugrel and
ticagrelor compared to
clopidogrel is better. This article widens the insight into the recent changes in antiplatelet
therapy in ACS by discussing the clinically most important data derived from the TRITON-TIMI 38 trial and the PLATO trial, including also the retrospective and pre-defined subgroup analyses. This article also gives information about the recommended duration of
DAPT and the situation when patients who need permanent anticoagulation (e.g. in case of non-valvular
atrial fibrillation) deserve also
DAPT after coronary stenting ('triple
therapy').