Advances in the Pharmacogenomics of Antiplatelet Therapy

Am J Ther. 2020 Sep/Oct;27(5):e477-e484. doi: 10.1097/MJT.0000000000001013.


Background: Acute coronary syndrome (ACS) is a highly thrombotic state, and a sustained antiplatelet effect is vital to the prevention of thrombotic complications. Clopidogrel, the most widely used oral P2Y12 receptor antagonist in ACS, has attracted considerable attention because of significant variability in antiplatelet effect depending on the presence of CYP2C19 allele. Other P2Y12 receptor antagonists offer sustained and more predictable antiplatelet effects than clopidogrel albeit at an increased cost. Several studies have demonstrated the promising application of pharmacogenetics in choosing personalized antiplatelet therapy using the point-of-care genotype assays.

Areas of uncertainty: Guidelines regarding the genotype-guided approach to the selection of antiplatelet therapy have been conflicting, and studies evaluating the effect of pharmacogenetic-guided selection of antiplatelet therapy on the outcomes have demonstrated mixed results.

Data sources: A literature search was conducted using MEDLINE and EMBASE for studies reporting the association of pharmacogenetic-guided selection of antiplatelet therapy and the outcomes in patients with ACS until December 2018.

Results: Presence of specific CYP2C19 allele significantly influences clopidogrel metabolism and associated outcomes in patients with ACS. Thrombotic and bleeding complications are more common in patients with loss-of-function (LOF) and gain-of-function (GOF) alleles, respectively. Although the pharmacogenetic-guided approach to the selection of antiplatelet therapy appears promising in ACS, studies have shown conflicting results, and direct randomized evidence linking this approach with the better outcomes is lacking.

Conclusions: Genotype-guided selection of antiplatelet therapy is expected to be useful in patients undergoing percutaneous coronary intervention (PCI) with a high risk of adverse outcomes. The patient-physician discussion should be an essential part of this decision-making process. Large-scale multicenter randomized controlled trials using the point-of-care genotype assay are needed to investigate this approach further before its use can be recommended in all comers.

Publication types

  • Review

MeSH terms

  • Acute Coronary Syndrome / drug therapy*
  • Alleles
  • Clinical Decision-Making / methods
  • Clopidogrel / pharmacology
  • Clopidogrel / therapeutic use
  • Cytochrome P-450 CYP2C19 / genetics
  • Cytochrome P-450 CYP2C19 / metabolism
  • Decision Making, Shared
  • Dual Anti-Platelet Therapy / methods*
  • Dual Anti-Platelet Therapy / standards
  • Embolism / epidemiology
  • Embolism / etiology
  • Embolism / prevention & control
  • Humans
  • Pharmacogenomic Testing / standards*
  • Pharmacogenomic Variants
  • Platelet Aggregation Inhibitors / pharmacology*
  • Platelet Aggregation Inhibitors / therapeutic use
  • Point-of-Care Testing / standards
  • Practice Guidelines as Topic
  • Precision Medicine / methods
  • Precision Medicine / standards
  • Receptors, Purinergic P2Y12 / metabolism
  • Thrombosis / epidemiology
  • Thrombosis / etiology
  • Thrombosis / prevention & control


  • P2RY12 protein, human
  • Platelet Aggregation Inhibitors
  • Receptors, Purinergic P2Y12
  • Clopidogrel
  • CYP2C19 protein, human
  • Cytochrome P-450 CYP2C19