The concept of clopidogrel resistance emerged several years ago. Since then, many studies have been performed to elucidate the mechanisms and potential clinical impact of this biological finding. These studies identified complex mechanisms, including drug-drug interactions, genetic polymorphisms and clinical factors, and showed consistently the clinical relevance of the variability of clopidogrel response, with higher ischaemic risk in low-responders or non-responders, and higher bleeding risk in hyper-responders. Several strategies for overcoming clopidogrel resistance have been evaluated in small clinical studies, but the benefit of tailored antiplatelet therapy has yet to be validated in large randomized trials, which are currently ongoing. Upcoming antiplatelet drugs that are more potent will change the field of antiplatelet therapy in acute coronary syndromes. The future of antiplatelet therapy sounds more complex, with different drugs, and tailored therapy based on platelet tests and/or genetic testing, but it will lead us to propose a more individualized therapy, which hopefully will improve patient outcome.
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