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Objective: We investigated whether prior clopidogrel influenced long-term ischaemic and bleeding risks and modified the randomised treatment effect of clopidogrel versus prasugrel among medically managed patients with acute coronary syndromes (ACS) treated with dual antiplatelet therapy.Methods: Medically managed patients with ACS in the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial were randomised to clopidogrel versus prasugrel (plus aspirin), stratified by prior clopidogrel use. From the analysis population (n=8927), we compared two groups: 'clopidogrel in-hospital (n=6513)' (clopidogrel started ≤72 h of presentation for index ACS event) and 'prior-clopidogrel (n=2414)' (on clopidogrel ≥5 days before index hospitalisation). Treatment-related differences in ischaemic (all-cause death, cardiovascular (CV) death, myocardial infarction (MI), stroke and the composite of CV death/MI/stroke) and bleeding outcomes (severe/life-threatening or moderate bleeding events based on Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) criteria) through 30 months were analysed between patients in the two groups.Results: Compared with 'clopidogrel in-hospital,' 'prior clopidogrel' patients were younger (median 64 years vs 66 years, p<0.001), more likely to have prior CV events/revascularisation, and had a higher frequency of CV death, MI or stroke through 30 months (20.8% vs 18.2%, p=0.002), with no difference in bleeding events (2.3% vs 3.4%, p=0.50). Randomised treatment effect (prasugrel vs clopidogrel) was similar for ischaemic and bleeding outcomes in both groups (all pinteraction>0.05).Conclusions: Patients receiving clopidogrel before admission for ACS and subsequently treated only medically are at higher risk for CV events versus those not previously receiving clopidogrel. More potent antiplatelet inhibition with prasugrel versus clopidogrel did not significantly reduce this risk.Trial Registration Number: NCT00699998. [ABSTRACT FROM AUTHOR]

Acute coronary syndromes (ACS) include unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). The management of ACS has improved greatly over the last 3 decades, with an associated steady decline in mortality from this condition seen in the US. The benefits of advances in the management of ACS observed in the US have not fully extended to Mexico, as thrombolytic therapy remains the most commonly used reperfusion strategy for STEMI and new antithrombotic drugs are not widely available. However, treatment of ACS in Mexico is rapidly evolving. Dual oral antiplatelet therapy with the combination of clopidogrel and aspirin (acetylsalicylic acid) is becoming the new standard of care for the management of patients with NSTEMI and those undergoing percutaneous coronary intervention. Results from controlled clinical studies strongly support the use of early and aggressive treatment with this combination. The addition of clopidogrel to the national formulary represents an important step in the evolution of care for ACS patients in Mexico. Local and regional leadership is required to foster the widespread adoption of this highly beneficial treatment strategy. The main objectives of this review are to highlight the recommendations of the Mexican guidelines for the management of ACS and provide some perspective regarding challenges to optimal management of ACS patients in Mexico. [ABSTRACT FROM AUTHOR]