Switching between P2Y 12 antagonists – From bench to bedside

Platelet P2Y 12 receptors play a key role in platelet activation and thrombus formation. Accordingly, P2Y 12 receptor antagonists are the cornerstone of secondary prevention of atherothrombotic events in patients undergoing percutaneous coronary intervention (PCI). The availability of different oral P2Y 12 antagonists (clopidogrel, prasugrel, ticagrelor) along with the introduction of the first intravenous P2Y 12 antagonist cangrelor offer an opportunity to individualize antiplatelet therapy according to the changing clinical setting. The recent International Expert Consensus provided the first recommendations on switching between the P2Y 12 antagonists. While the consensus greatly helps to guide switching between P2Y 12 antagonists, a number of controversial clinical scenarios remain where the evidence regarding the optimal switch strategy is scarce. In such clinical scenarios, understanding of the (i) pharmacological properties of P2Y 12 antagonists, (ii) recent evidence from pharmacodynamics studies, clinical trials and registries, and (iii) factors affecting the efficacy and safety of the P2Y 12 antagonists, all summarized below, are crucial to choose the optimal switch strategy.