Ticagrelor, prasugrel, or clopidogrel in ST-segment elevation myocardial infarction: which one to choose?

Introduction: Clopidogrel, prasugrel, and ticagrelor are the currently available oral P2Y12 inhibitors for the treatment of ST-segment elevation myocardial infarction (STEM!), in association with aspirin. These agents bind the P2Y12 platelet receptor and thus inhibit platelet aggregation. Large randomized clinical trials have provided efficacy and safety data on P2Y12 inhibitors in STEMI patients. Areas covered: This review focuses on key pharmacologic and clinical aspects of clopidogrel, prasugrel, and ticagrelor, highlighting their differences. Results from the main clinical trials are discussed, as well as the current STEMI guideline recommendations, to help inform agent selection for patients presenting with STEMI. Expert opinion: Clinical trials studying newer P2Y12 inhibitors with increased potency have shown further reduction of cardiovascular events compared with clopidogrel, therefore suggesting the use of ticagrelor or prasugrel as a first-line agent for STEM! treatment. There are still clinical situations - such as fibrinolysis, high risk of bleeding, use of oral anticoagulant, and financial hurdles - in which clopidogrel maintains a role in the treatment of STEMI.