1. Prasugrel in all ACS Patients! Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Italy giuseppe.biondizoccai@uniroma1.it

2. First and foremost: both prasugrel and ticagrelor are lifesaving vs clopidogrel Biondi-Zoccai et al, Int J Cardiol 2011

3. Prasugrel has an established and favorable risk-benefit profile Wiviott et al, New Engl J Med 2008

4. Risk stratification is of course key Montalescot et al, Lancet 2009

5. Short-term regimens are not enough Murphy et al, Eur Heart J 2008

6. Dose adjustment is possible Erlinge et al, J Am Coll Cardiol 2012

7. Loading with both clopidogrel and prasugrel is not prohibitive Loh et al, Am J Cardiol 2013

8. Particularly risk-beneficial in diabetics Wiviott et al, Circulation 2008

9. And even more so in IDDM Wiviott et al, Circulation 2008

10. Non-CABG bleeding also ↑ by ticagrelor Wallentin et al, New Engl J Med 2009

11. And are shortness of breath and bradyarrhythmias minor issues? Wallentin et al, New Engl J Med 2009

12. Last but not least Are you afraid of increased neoplastic risk after assuming prasugrel? Do you know how long does it take to develop cancer after you are exposed to a nuclear bomb (e.g. Hiroshima)? Any purported association between prasugrel and cancer risk in TRITON-TIMI 38 patently lacks biologic plausibility

13. Do you trust platelet responsiveness assays? Alexopoulos et al, J Am Coll Cardiol 2012

14. I personally don’t Biondi-Zoccai et al, BMJ 2008 (but also Gurbel et al, JAMA 2012; Collet et al, NEJM 2012; Gaglia et al, Cardiovasc Revasc Med 2013; etc)

15. Even if you believe… Alexopoulos et al, Circ Cardiovasc Interv 2012

16. Adjusted indirect comparison Biondi-Zoccai et al, Int J Cardiol 2011

17. Adjusted indirect comparison Biondi-Zoccai et al, Int J Cardiol 2011

18. Adjusted indirect comparison Biondi-Zoccai et al, Int J Cardiol 2011

19. Reconciling the evidence Biondi-Zoccai et al, Curr Vasc Pharmacol 2012

20. Many thanks for your attention For these slides and further ones on similar topics feel free to visit: www.metcardio.org/slides.html For additional details or queries feel free to contact me directly: giuseppe.biondizoccai@uniroma1.it