Oral Antiplatelet Therapy After Acute Coronary Syndrome: A Review | Acute Coronary Syndromes | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Oral Antiplatelet Therapy After Acute Coronary SyndromeA Review

Educational Objective
To review the clinical management of patients with acute coronary syndrome.
1 Credit CME

Importance  Acute coronary syndrome (ACS) is a major cause of morbidity and mortality in the United States with an annual incidence of approximately 1 million. Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) reduces cardiovascular event rates after ACS.

Observations  In 2016, the updated guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommended aspirin plus a P2Y12 inhibitor for at least 12 months for patients with ACS. Since these recommendations were published, new randomized clinical trials have studied different regimens and durations of antiplatelet therapy. Recommendations vary according to the risk of bleeding. If bleeding risk is low, prolonged DAPT may be considered, although the optimal duration of prolonged DAPT beyond 1 year is not well established. If bleeding risk is high, shorter duration (ie, 3-6 months) of DAPT may be reasonable. A high risk of bleeding traditionally is defined as a 1-year risk of serious bleeding (either fatal or associated with a ≥3-g/dL drop in hemoglobin) of at least 4% or a risk of an intracranial hemorrhage of at least 1%. Patients at higher risk are 65 years old or older; have low body weight (BMI <18.5), diabetes, or prior bleeding; or take oral anticoagulants. The newest P2Y12 inhibitors, prasugrel and ticagrelor, are more potent, with high on-treatment residual platelet reactivity of about 3% vs 30% to 40% with clopidogrel and act within 30 minutes compared with 2 hours for clopidogrel. Clinicians should avoid prescribing prasugrel to patients with a history of stroke or transient ischemic attack because of an increased risk of cerebrovascular events (6.5% vs 1.2% with clopidogrel, P = .002) and should avoid prescribing it to patients older than 75 years or who weigh less than 60 kg. The ISAR-REACT-5 trial found that prasugrel reduced rates of death, myocardial infarction, or stroke at 1 year compared with ticagrelor among patients with ACS undergoing percutaneous coronary intervention (9.3% vs 6.9%, P = .006) with no significant difference in bleeding. Recent trials suggested that discontinuing aspirin rather than the P2Y12 inhibitor may be associated with better outcomes.

Conclusions and Relevance  Dual antiplatelet therapy reduces rates of cardiovascular events in patients with acute coronary syndrome. Specific combinations and duration of dual antiplatelet therapy should be based on patient characteristics—risk of bleeding myocardial ischemia.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Umair Khalid, MD, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd (Mail Code: 111B), VAMC Office 3C-320A, Houston, TX 77030 (mukhalid@bcm.edu).

Correction: This article was corrected on June 13, 2021, to amend aspirin’s role in irreversibly inhibiting platelet activation and to change reference 19.

Accepted for Publication: January 19, 2021.

Author Contributions: Dr Khalid had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kamran, Jneid, Virani, Nambi, Khalid.

Acquisition, analysis, or interpretation of data: Kamran, Kayani, Levine.

Drafting of the manuscript: Kamran, Kayani, Khalid.

Critical revision of the manuscript for important intellectual content: Kamran, Jneid, Kayani, Virani, Levine, Nambi.

Administrative, technical, or material support: Kamran.

Supervision: Jneid, Kayani, Virani, Khalid.

Other - focus and presentation of data: Levine.

Conflict of Interest Disclosures: Dr Virani reported receiving research grants from the Department of Veterans Affairs, World Heart Federation, and the Tahir and Jooma Family and honorarium from the American College of Cardiology for serving as an associate editor for the Innovations section of the ACC.org editorial board; and serving on the steering committee of the Patient and Provider Assessment of Lipid Management (PALM). Dr Nambi reported receiving a research grant from the Department of Veterans Affairs; being a site primary investigator for studies sponsored by Merck, Amgen; receiving personal fees from Dynamed; and having a patent pending along with Roche and Baylor College of Medicine for the use of biomarkers in prediction of heart failure. No other disclosures were reported.

Benjamin  EJ , Muntner  P , Alonso  A ,  et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics-2019 update: a report from the American Heart Association.   Circulation. 2019;139(10):e56-e528. doi:10.1161/CIR.0000000000000659 PubMedGoogle ScholarCrossref
Amsterdam  EA , Wenger  NK , Brindis  RG ,  et al; ACC/AHA Task Force Members; Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.  2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: executive summary.   Circulation. 2014;130(25):2354-2394. doi:10.1161/CIR.0000000000000133 PubMedGoogle ScholarCrossref
Levine  GN , Bates  ER , Bittl  JA ,  et al.  A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery.   Circulation. 2016;134(10):e123-e155. doi:10.1161/CIR.0000000000000404PubMedGoogle ScholarCrossref
Palmerini  T , Bruno  AG , Gilard  M ,  et al.  Risk-benefit profile of longer-than-1-year dual-antiplatelet therapy duration after drug-eluting stent implantation in relation to clinical presentation a pairwise meta-analysis of 6 trials and 21 457 patients.   Circ Cardiovasc Interv. 2019;12(3):e007541. doi:10.1161/CIRCINTERVENTIONS.118.007541 PubMedGoogle Scholar
Valgimigli  M , Bueno  H , Byrne  RA ,  et al.  ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS.   Eur Heart J. 2018;39(3):213-260. doi:10.1093/eurheartj/ehx419 PubMedGoogle ScholarCrossref
Collet  J-P , Thiele  H , Barbato  E ,  et al.  2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.   Eur Heart J. Published online August 29, 2020. PubMedGoogle Scholar
Santos-Gallego  CG , Picatoste  B , Badimón  JJ .  Pathophysiology of acute coronary syndrome.   Curr Atheroscler Rep. 2014;16(4):401. doi:10.1007/s11883-014-0401-9 PubMedGoogle ScholarCrossref
Ong  P , Athanasiadis  A , Hill  S , Vogelsberg  H , Voehringer  M , Sechtem  U .  Coronary artery spasm as a frequent cause of acute coronary syndrome: the CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) study.   J Am Coll Cardiol. 2008;52(7):523-527. doi:10.1016/j.jacc.2008.04.050 PubMedGoogle ScholarCrossref
Tamis-Holland  JE , Jneid  H , Reynolds  HR ,  et al; American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; and Council on Quality of Care and Outcomes Research.  Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association.   Circulation. 2019;139(18):e891-e908. doi:10.1161/CIR.0000000000000670 PubMedGoogle ScholarCrossref
Wei  J , Cheng  S , Merz  CNB .  Coronary microvascular dysfunction causing cardiac ischemia in women.   JAMA. 2019;322(23):2334-2335. doi:10.1001/jama.2019.15736 PubMedGoogle ScholarCrossref
Reynolds  HR , Maehara  A , Kwong  RY ,  et al.  Coronary optical coherence tomography and cardiac magnetic resonance imaging to determine underlying causes of myocardial infarction with nonobstructive coronary arteries in women.   Circulation. 2021;143(7):624-640. doi:10.1161/CIRCULATIONAHA.120.052008 PubMedGoogle ScholarCrossref
Fitridge  R , Thompson  M , eds.  Mechanisms of Vascular Disease: A Reference Book for Vascular Specialists. University of Adelaide Press; 2011.
Badimon  L , Padró  T , Vilahur  G .  Atherosclerosis, platelets and thrombosis in acute ischaemic heart disease.   Eur Heart J Acute Cardiovasc Care. 2012;1(1):60-74. doi:10.1177/2048872612441582 PubMedGoogle ScholarCrossref
Chaabane  C , Otsuka  F , Virmani  R , Bochaton-Piallat  ML .  Biological responses in stented arteries.   Cardiovasc Res. 2013;99(2):353-363. doi:10.1093/cvr/cvt115 PubMedGoogle ScholarCrossref
Brilakis  ES , Patel  VG , Banerjee  S .  Medical management after coronary stent implantation: a review.   JAMA. 2013;310(2):189-198. doi:10.1001/jama.2013.7086 PubMedGoogle ScholarCrossref
Lee  DH , de la Torre Hernandez  JM .  The newest generation of drug-eluting stents and beyond.   Eur Cardiol. 2018;13(1):54-59. doi:10.15420/ecr.2018:8:2 PubMedGoogle ScholarCrossref
Marx  SO , Totary-Jain  H , Marks  AR .  Vascular smooth muscle cell proliferation in restenosis.   Circ Cardiovasc Interv. 2011;4(1):104-111. doi:10.1161/CIRCINTERVENTIONS.110.957332 PubMedGoogle ScholarCrossref
Cornelissen  A , Vogt  FJ .  The effects of stenting on coronary endothelium from a molecular biological view: time for improvement?   J Cell Mol Med. 2019;23(1):39-46. doi:10.1111/jcmm.13936 PubMedGoogle ScholarCrossref
Lucotti  S , Cerutti  C , Soyer  M ,  et al.  Aspirin blocks formation of metastatic intravascular niches by inhibiting platelet-derived COX-1/thromboxane A2.   J Clin Invest. 2019;129(5):1845-1862. doi:10.1172/JCI121985PubMedGoogle ScholarCrossref
 Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2.ISIS-2 (Second International Study of Infarct Survival) Collaborative Group.   J Am Coll Cardiol. 1988;12(6)(suppl A):3A-13A. doi:10.1016/0735-1097(88)92635-6 PubMedGoogle ScholarCrossref
Antithrombotic Trialists’ Collaboration.  Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.   BMJ. 2002;324(7329):71-86. doi:10.1136/bmj.324.7329.71 PubMedGoogle ScholarCrossref
Lewis  HD  Jr , Davis  JW , Archibald  DG ,  et al.  Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina: results of a Veterans Administration cooperative study.   N Engl J Med. 1983;309(7):396-403. doi:10.1056/NEJM198308183090703 PubMedGoogle ScholarCrossref
Mehta  SR , Bassand  JP , Chrolavicius  S ,  et al; CURRENT-OASIS 7 Investigators.  Dose comparisons of clopidogrel and aspirin in acute coronary syndromes.   N Engl J Med. 2010;363(10):930-942. doi:10.1056/NEJMoa0909475 PubMedGoogle Scholar
Yusuf  S , Zhao  F , Mehta  SR , Chrolavicius  S , Tognoni  G , Fox  KK ; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators.  Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation.   N Engl J Med. 2001;345(7):494-502. doi:10.1056/NEJMoa010746 PubMedGoogle Scholar
CAPRIE Steering Committee.  A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE).   Lancet. 1996;348(9038):1329-1339. doi:10.1016/S0140-6736(96)09457-3 PubMedGoogle ScholarCrossref
Steinhubl  SR , Berger  PB , Mann  JT  III ,  et al; CREDO Investigators.  Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial.   JAMA. 2002;288(19):2411-2420. doi:10.1001/jama.288.19.2411 PubMedGoogle ScholarCrossref
Sabatine  MS , Cannon  CP , Gibson  CM ,  et al; CLARITY-TIMI 28 Investigators.  Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation.   N Engl J Med. 2005;352(12):1179-1189. doi:10.1056/NEJMoa050522 PubMedGoogle ScholarCrossref
Wallentin  L , Becker  RC , Budaj  A ,  et al; PLATO Investigators.  Ticagrelor versus clopidogrel in patients with acute coronary syndromes.   N Engl J Med. 2009;361(11):1045-1057. doi:10.1056/NEJMoa0904327 PubMedGoogle ScholarCrossref
Bonaca  MP , Bhatt  DL , Cohen  M ,  et al; PEGASUS-TIMI 54 Steering Committee and Investigators.  Long-term use of ticagrelor in patients with prior myocardial infarction.   N Engl J Med. 2015;372(19):1791-1800. doi:10.1056/NEJMoa1500857 PubMedGoogle ScholarCrossref
Wiviott  SD , Braunwald  E , McCabe  CH ,  et al; TRITON-TIMI 38 Investigators.  Prasugrel versus clopidogrel in patients with acute coronary syndromes.   N Engl J Med. 2007;357(20):2001-2015. doi:10.1056/NEJMoa0706482 PubMedGoogle ScholarCrossref
Roe  MT , Armstrong  PW , Fox  KAA ,  et al; TRILOGY ACS Investigators.  Prasugrel versus clopidogrel for acute coronary syndromes without revascularization.   N Engl J Med. 2012;367(14):1297-1309. doi:10.1056/NEJMoa1205512 PubMedGoogle ScholarCrossref
Montalescot  G , Bolognese  L , Dudek  D ,  et al; ACCOAST Investigators.  Pretreatment with prasugrel in non–ST-segment elevation acute coronary syndromes.   N Engl J Med. 2013;369(11):999-1010. doi:10.1056/NEJMoa1308075 PubMedGoogle ScholarCrossref
Schüpke  S , Neumann  FJ , Menichelli  M ,  et al; ISAR-REACT 5 Trial Investigators.  Ticagrelor or prasugrel in patients with acute coronary syndromes.   N Engl J Med. 2019;381(16):1524-1534. doi:10.1056/NEJMoa1908973 PubMedGoogle ScholarCrossref
Tricoci  P , Huang  Z , Held  C ,  et al; TRACER Investigators.  Thrombin-receptor antagonist vorapaxar in acute coronary syndromes.   N Engl J Med. 2012;366(1):20-33. doi:10.1056/NEJMoa1109719 PubMedGoogle ScholarCrossref
Morrow  DA , Braunwald  E , Bonaca  MP ,  et al; TRA 2P–TIMI 50 Steering Committee and Investigators.  Vorapaxar in the secondary prevention of atherothrombotic events.   N Engl J Med. 2012;366(15):1404-1413. doi:10.1056/NEJMoa1200933 PubMedGoogle ScholarCrossref
Mehta  SR , Yusuf  S , Peters  RJG ,  et al; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial (CURE) Investigators.  Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study.   Lancet. 2001;358(9281):527-533. doi:10.1016/S0140-6736(01)05701-4 PubMedGoogle ScholarCrossref
Wallentin  L .  P2Y(12) inhibitors: differences in properties and mechanisms of action and potential consequences for clinical use.   Eur Heart J. 2009;30(16):1964-1977. doi:10.1093/eurheartj/ehp296 PubMedGoogle ScholarCrossref
Sangkuhl  K , Klein  TE , Altman  RB .  Clopidogrel pathway.   Pharmacogenet Genomics. 2010;20(7):463-465. doi:10.1097/FPC.0b013e3283385420 PubMedGoogle ScholarCrossref
Norgard  NB , Abu-Fadel  M .  Comparison of prasugrel and clopidogrel in patients with acute coronary syndrome undergoing percutaneous coronary intervention.   Vasc Health Risk Manag. 2009;5:873-882. doi:10.2147/VHRM.S5699 PubMedGoogle Scholar
Wiviott  SD , Antman  EM , Braunwald  E .  Prasugrel.   Circulation. 2010;122(4):394-403. doi:10.1161/CIRCULATIONAHA.109.921502 PubMedGoogle ScholarCrossref
Effient (prasugrel). Prescribing information. Eli Lilly and Co; 2009. Published 2009. Revised March 2019. Accessed March 23, 2021. https://pi.lilly.com/us/effient.pdf
Riesmeyer  JS , Salazar  DE , Weerakkody  GJ ,  et al.  Relationship between exposure to prasugrel active metabolite and clinical outcomes in the TRITON-TIMI 38 substudy.   J Clin Pharmacol. 2012;52(6):789-797. doi:10.1177/0091270011406280 PubMedGoogle ScholarCrossref
Roe  MT , Goodman  SG , Ohman  EM ,  et al.  Elderly patients with acute coronary syndromes managed without revascularization: insights into the safety of long-term dual antiplatelet therapy with reduced-dose prasugrel versus standard-dose clopidogrel.   Circulation. 2013;128(8):823-833. doi:10.1161/CIRCULATIONAHA.113.002303 PubMedGoogle ScholarCrossref
Dobesh  PP , Oestreich  JH .  Ticagrelor: pharmacokinetics, pharmacodynamics, clinical efficacy, and safety.   Pharmacotherapy. 2014;34(10):1077-1090. doi:10.1002/phar.1477 PubMedGoogle ScholarCrossref
Parodi  G , Storey  RF .  Dyspnoea management in acute coronary syndrome patients treated with ticagrelor.   Eur Heart J Acute Cardiovasc Care. 2015;4(6):555-560. doi:10.1177/2048872614554108 PubMedGoogle ScholarCrossref
Cannon  CP , Harrington  RA , James  S ,  et al; PLATelet inhibition and patient Outcomes Investigators.  Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study.   Lancet. 2010;375(9711):283-293. doi:10.1016/S0140-6736(09)62191-7 PubMedGoogle ScholarCrossref
Mahaffey  KW , Wojdyla  DM , Carroll  K ,  et al; PLATO Investigators.  Ticagrelor compared with clopidogrel by geographic region in the Platelet Inhibition and Patient Outcomes (PLATO) trial.   Circulation. 2011;124(5):544-554. doi:10.1161/CIRCULATIONAHA.111.047498 PubMedGoogle ScholarCrossref
Brilinta (ticagrelor). Prescribing information. AstraZeneca; 2011. Revised November 2020. Accessed March 23, 2021. https://www.azpicentral.com/brilinta/brilinta.pdf
Bonaca  MP , Scirica  BM , Creager  MA ,  et al.  Vorapaxar in patients with peripheral artery disease: results from TRA 2P–TIMI 50.   Circulation. 2013;127(14):1522-1529, 1529e1-6. doi:10.1161/CIRCULATIONAHA.112.000679 PubMedGoogle ScholarCrossref
Tada  T , Byrne  RA , Simunovic  I ,  et al.  Risk of stent thrombosis among bare-metal stents, first-generation drug-eluting stents, and second-generation drug-eluting stents: results from a registry of 18,334 patients.   JACC Cardiovasc Interv. 2013;6(12):1267-1274. doi:10.1016/j.jcin.2013.06.015 PubMedGoogle ScholarCrossref
Bittl  JA , Baber  U , Bradley  SM , Wijeysundera  DN .  Duration of Dual Antiplatelet Therapy: a systematic review for the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.   J Am Coll Cardiol. 2016;68(10):1116-1139. doi:10.1016/j.jacc.2016.03.512 PubMedGoogle ScholarCrossref
Yeh  RW , Secemsky  EA , Kereiakes  DJ ,  et al; DAPT Study Investigators.  Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention.   JAMA. 2016;315(16):1735-1749. doi:10.1001/jama.2016.3775 PubMedGoogle ScholarCrossref
Palmerini  T , Della Riva  D , Benedetto  U ,  et al.  Three, six, or twelve months of dual antiplatelet therapy after DES implantation in patients with or without acute coronary syndromes: an individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients.   Eur Heart J. 2017;38(14):1034-1043. doi:10.1093/eurheartj/ehw627 PubMedGoogle Scholar
Watanabe  H , Domei  T , Morimoto  T ,  et al; STOPDAPT-2 Investigators.  Effect of 1-month dual antiplatelet therapy followed by clopidogrel vs 12-month dual antiplatelet therapy on cardiovascular and bleeding events in patients receiving PCI: The STOPDAPT-2 randomized clinical trial.   JAMA. 2019;321(24):2414-2427. doi:10.1001/jama.2019.8145 PubMedGoogle ScholarCrossref
Mehran  R , Baber  U , Sharma  SK ,  et al.  Ticagrelor with or without aspirin in high-risk patients after PCI.   N Engl J Med. 2019;381(21):2032-2042. doi:10.1056/NEJMoa1908419 PubMedGoogle ScholarCrossref
Kim  BK , Hong  SJ , Cho  YH ,  et al; TICO Investigators.  Effect of ticagrelor monotherapy vs ticagrelor with aspirin on major bleeding and cardiovascular events in patients with acute coronary syndrome: the TICO randomized clinical trial.   JAMA. 2020;323(23):2407-2416. doi:10.1001/jama.2020.7580 PubMedGoogle ScholarCrossref
O’Donoghue  ML , Murphy  SA , Sabatine  MS .  The safety and efficacy of aspirin discontinuation on a background of a P2Y12 inhibitor in patients after percutaneous coronary intervention: a systematic review and meta-analysis.   Circulation. 2020;142(6):538-545. doi:10.1161/CIRCULATIONAHA.120.046251 PubMedGoogle ScholarCrossref
Mason  PJ , Jacobs  AK , Freedman  JE .  Aspirin resistance and atherothrombotic disease.   J Am Coll Cardiol. 2005;46(6):986-993. doi:10.1016/j.jacc.2004.08.070 PubMedGoogle ScholarCrossref
Maree  AO , Curtin  RJ , Dooley  M ,  et al.  Platelet response to low-dose enteric-coated aspirin in patients with stable cardiovascular disease.   J Am Coll Cardiol. 2005;46(7):1258-1263. doi:10.1016/j.jacc.2005.06.058 PubMedGoogle ScholarCrossref
Mega  JL , Close  SL , Wiviott  SD ,  et al.  Cytochrome p-450 polymorphisms and response to clopidogrel.   N Engl J Med. 2009;360(4):354-362. doi:10.1056/NEJMoa0809171 PubMedGoogle ScholarCrossref
Giusti  B , Gori  AM , Marcucci  R ,  et al.  Relation of cytochrome P450 2C19 loss-of-function polymorphism to occurrence of drug-eluting coronary stent thrombosis.   Am J Cardiol. 2009;103(6):806-811. doi:10.1016/j.amjcard.2008.11.048 PubMedGoogle ScholarCrossref
Collet  JP , Cuisset  T , Rangé  G ,  et al; ARCTIC Investigators.  Bedside monitoring to adjust antiplatelet therapy for coronary stenting.   N Engl J Med. 2012;367(22):2100-2109. doi:10.1056/NEJMoa1209979 PubMedGoogle ScholarCrossref
Montalescot  G , Rangé  G , Silvain  J ,  et al; ARCTIC Investigators.  High on-treatment platelet reactivity as a risk factor for secondary prevention after coronary stent revascularization: a landmark analysis of the ARCTIC study.   Circulation. 2014;129(21):2136-2143. doi:10.1161/CIRCULATIONAHA.113.007524 PubMedGoogle ScholarCrossref
Cannon  CP , Husted  S , Harrington  RA ,  et al; DISPERSE-2 Investigators.  Safety, tolerability, and initial efficacy of AZD6140, the first reversible oral adenosine diphosphate receptor antagonist, compared with clopidogrel, in patients with non–ST-segment elevation acute coronary syndrome: primary results of the DISPERSE-2 trial.   J Am Coll Cardiol. 2007;50(19):1844-1851. doi:10.1016/j.jacc.2007.07.053 PubMedGoogle ScholarCrossref
Mega  JL , Close  SL , Wiviott  SD ,  et al.  Cytochrome P450 genetic polymorphisms and the response to prasugrel: relationship to pharmacokinetic, pharmacodynamic, and clinical outcomes.   Circulation. 2009;119(19):2553-2560. doi:10.1161/CIRCULATIONAHA.109.851949 PubMedGoogle ScholarCrossref
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity



My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right