Table 1

Summary of antiplatelet agents for secondary prevention

DrugMechanismActionOnset of platelet inhibitionBiotransformationIndicationsContraindicationsWarnings
AspirinInhibition of cyclo-oxygenase-1Irreversible30–40 minHydrolysis by esteraseStable coronary artery disease
Acute coronary syndromes
Active pathological bleeding
Hypersensitivity to aspirin
Severe hepatic impairment
Severe hepatic impairment
Severe renal insufficiency
Severely decompensated heart failure
Interaction with NSAIDs
Combination with methotrexate
ClopidogrelInhibition of P2Y12 unit of ADP-receptorIrreversible5–8% inhibition of platelet aggregation after 30 minutes*†Cytochrom-P450-dependent oxidation (affected by genetic variability)Stable coronary artery disease
Acute coronary syndromes
Active pathological bleeding
Severe hepatic impairment
Thrombotic thrombocytopenic purpura
Recent (<7 days) ischaemic stroke
Poor CYP2C19 metabolisers
Renal impairment
Galactose intolerance
Concomitant use of omeprazole and esomeprazole
PrasugrelInhibition of P2Y12 unit of ADP-receptorIrreversible31% inhibition of platelet aggregation after 30 minutes*Hydrolysis by carboxylesterase and cytochrom-P450-dependent oxidation (unaffected by genetic variability)Acute coronary syndromes with PCIActive pathological bleeding
History of stroke or TIA
Severe hepatic impairment (Child-Pugh class C)
For age ≥75 years use of 5 mg dose
For body weight <60 kg use 5 mg dose
Thrombotic thrombocytopenic purpura
Galactose intolerance
TicagrelorInhibition of P2Y12 unit of ADP-receptorReversible41% inhibition of platelet aggregation after 30 minutes†NoneAcute coronary syndromesActive pathological bleeding
History of intracranial haemorrhage
Moderate to severe hepatic impairment
Co-administration with strong CYP3A4 inhibitors
Bradycardic events
Asthma and/or COPD
Moderate/severe renal impairment
Concomitant use of ARBs
Hyperuricaemia or gouty arthritis
Uric acid nephropathy
Co-administration of simvastatin /lovastatin >40 mg
Co-administration of digoxin
  • *Wiviott, Circulation 2007;116:2923–32.

  • †Gurbel, Circulation 2009;120:2577–85.

  • ARB, angiotensin recepor blocker; COPD, chronic obstructive pulmonary disease; TIA, transient ischaemic attack; NSAID, non-steroidal anti-inflammatory drugs; PCI, percutaneous coronary intervention.