When initiating dual antiplatelet therapy in ACS, which sequence and agents are typical?

• A. Before aspirin, with a P2Y12 inhibitor
• B. With anticoagulation instead of antiplatelets
• C. After aspirin, with a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) depending on PCI plan and bleeding risk; continued for months to a year depending on stent type
• D. Only aspirin, no P2Y12 inhibitor

Answer: (C)

Initiating dual antiplatelet therapy in ACS hinges on giving aspirin first to rapidly inhibit platelet activation, then adding a P2Y12 inhibitor to enhance antiplatelet effect. The P2Y12 inhibitor options include clopidogrel, ticagrelor, or prasugrel, and the choice depends on whether coronary intervention is planned and the patient’s bleeding risk. If PCI is planned, a more potent P2Y12 inhibitor is often used, with clopidogrel reserved for certain patients or resource-limited settings. After this loading, dual therapy is continued for a period determined by the stent type and bleeding risk—generally months to up to a year for most patients with drug-eluting stents, shorter with bare-metal stents, and adjusted if bleeding risk is high. The essential idea is aspirin followed by a P2Y12 inhibitor, with duration tailored to the stent and patient safety.