Hot Topics in Cardiology - Editors-in-chief: Sergio Dalla Volta, Christopher P. Cannon

In the past decade, no area of cardiology has been "hotter" than antiplatelet therapy. There has been a revolution in treatment, and it is ongoing.
It began with the addition of ticlopidine to aspirin for prevention of stent thrombosis, as compared to the then standard therapy of aspirin, heparin, sometimes dextran or warfarin. The benefit of dual antiplatelet therapy was huge — a nearly 75% reduction in clinical events. Then, clopidogrel was developed to avoid the hematologic side effects (neutropenia, thrombocytopenia, and thrombotic thrombocytopenic purpura) of ticlopidine. It had no such side effect, and was then used in stenting and in post-stroke prevention. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial found that clopidogrel plus aspirin was more beneficial than aspirin alone in patients with unstable angina or non-ST elevation myocardial infarction (non-STEMI). Benefit was also seen in STEMI, and use expanded greatly. Now there are two new agents that are also P₂Y₁₂ inhibitors, but more potent: prasugrel, a third generation thienopyridine, and ticagrelor, the first direct P₂Y₁₂ inhibitor that is a reversible oral agent. Both agents produce approximately double the antiplatelet effect of clopidogrel, and each reduced recurrent cardiovascular events over a 12- to 15-month period post-percutaneous coronary intervention and/or acute coronary syndrome. Other agents are being evaluated as well.
Bonaca and Giugliano provide a complete and up-to-the-minute summary of this rapidly evolving field. It is an excellent "state-of-the-art" of oral antiplatelet therapy that I can enthusiastically recommend to everyone.