Antiplatelet Drug Selection Tool
This tool helps determine which antiplatelet drug may be most appropriate for you based on your specific health factors. Select your characteristics below to see which drug is recommended by current guidelines.
When you’ve had a heart attack or a stent placed, your doctor doesn’t just hand you a pill and say "take this." They’re trying to stop another clot from forming-right now, in your arteries. Prasugrel is one of the strongest tools for that job. But it’s not the only one. And for some people, it’s not even the best. So how do you know if prasugrel is right for you-or if another drug might work better with fewer risks?
What Prasugrel Actually Does
Prasugrel, sold under the brand name Effient, is an antiplatelet drug. That means it stops your blood platelets from sticking together and forming clots. After a heart attack or stent placement, clots can block blood flow again-and that’s deadly. Prasugrel blocks a specific receptor on platelets called P2Y12. It does this faster and more completely than older drugs like clopidogrel.
Studies show prasugrel reduces the risk of another heart attack or stroke by about 19% compared to clopidogrel in high-risk patients, according to the TRITON-TIMI 38 trial. But here’s the catch: that same study found a 50% higher risk of serious bleeding. Not every patient needs that level of protection. Some need safety more than strength.
Clopidogrel: The Older, Cheaper Option
Clopidogrel (Plavix) was the go-to drug for over a decade before prasugrel and ticagrelor came along. It’s cheaper, often available as a generic, and has been used in millions of patients worldwide. But it doesn’t work the same way.
Clopidogrel needs to be converted by the liver into its active form. That process varies wildly between people. About 30% of patients are "poor metabolizers"-their bodies don’t turn clopidogrel into the drug it needs to be. That means it doesn’t work well for them. Genetic testing can find this, but most doctors don’t test unless there’s a clear reason.
Prasugrel doesn’t have that problem. It’s activated faster and more reliably. So if you’re a poor metabolizer, clopidogrel might be doing almost nothing. Prasugrel? It’s working.
But prasugrel’s strength comes with a cost. If you’re over 75, weigh less than 60 kg, or have a history of stroke or TIA, guidelines from the American Heart Association strongly advise against prasugrel. The bleeding risk is too high. For those patients, clopidogrel is still the standard.
Ticagrelor: The New Kid on the Block
Ticagrelor (Brilinta) is the third major player. Like prasugrel, it’s a direct-acting P2Y12 inhibitor-no liver conversion needed. But it works differently. It binds reversibly, meaning its effect wears off faster if you stop taking it. That’s a double-edged sword.
On the plus side: ticagrelor has a lower risk of severe bleeding than prasugrel. In the PLATO trial, it reduced cardiovascular death by 21% compared to clopidogrel, with similar clot prevention. It’s also the only one of the three proven to reduce overall death rates in heart attack patients.
On the downside: ticagrelor causes more shortness of breath. About 15% of people report it, and it can be scary. It also needs to be taken twice daily, unlike prasugrel, which is once a day. And it’s more expensive than clopidogrel.
For patients under 75, without a history of stroke, and who can handle twice-daily dosing, ticagrelor is often the first choice today. It’s not as strong as prasugrel at preventing clots, but it’s safer overall.
When Doctors Choose Prasugrel
Prasugrel isn’t the default anymore. But it still has its place. Here’s when it’s likely the best option:
- You’re under 75 and weigh more than 60 kg
- You’ve had a heart attack with a stent placed
- You’re at high risk for another clot-maybe you’re diabetic, had a large heart attack, or had a stent in a critical artery
- You’ve tried clopidogrel and it didn’t work (confirmed by platelet testing)
- You don’t have a history of stroke, TIA, or major bleeding
Doctors in Melbourne, Sydney, and Brisbane now routinely check a patient’s bleeding risk score before prescribing prasugrel. If you’re on warfarin, have ulcers, or are scheduled for surgery soon, prasugrel is usually off the table.
What About Other Drugs?
There are other antiplatelet drugs, but they’re not used as first-line after heart attacks. Cilostazol is sometimes added for leg artery disease. Dipyridamole is used with aspirin for stroke prevention. But for acute coronary syndrome or stent patients, the only three real options are clopidogrel, prasugrel, and ticagrelor.
Some patients ask about aspirin alone. Aspirin is still part of the treatment-but it’s not enough by itself. All three drugs are used with low-dose aspirin (75-100 mg daily). You need both.
Cost and Accessibility
Price matters. In Australia, clopidogrel costs about $5 per month as a generic. Prasugrel and ticagrelor cost $30-$40 per month, even with PBS subsidies. If you’re on a fixed income or don’t qualify for government help, cost can steer the decision.
But here’s the thing: if prasugrel or ticagrelor prevents one more heart attack, it saves thousands in hospital bills and long-term care. Many doctors will push for the better drug if you’re young and healthy enough to handle it. Insurance often covers it for high-risk cases.
Side Effects You Can’t Ignore
All three drugs can cause bleeding. That means nosebleeds, bruising easily, or blood in urine or stool. But prasugrel carries the highest risk. Ticagrelor can cause breathing trouble. Clopidogrel might cause diarrhea or rash.
Prasugrel also has a rare but serious risk: thrombotic thrombocytopenic purpura (TTP). It’s extremely rare-less than 1 in 10,000-but it’s life-threatening. If you suddenly feel tired, have yellow skin, confusion, or unexplained bruising, go to the ER immediately.
None of these drugs are safe if you’re pregnant or breastfeeding. Talk to your doctor before stopping or switching.
What If You’re Still Having Clots?
Some patients take their meds exactly as prescribed-and still have another heart event. That’s called "resistance." It’s not always about the drug. Sometimes it’s about how well you’re managing other risks: smoking, cholesterol, blood pressure, or diabetes.
If you’ve had a clot despite being on clopidogrel, your doctor might test your platelet function. If the test shows you’re not responding, switching to prasugrel or ticagrelor often fixes it. But if you’re already on prasugrel and still clotting, the issue might not be the drug. It could be an untreated artery, poor lifestyle, or another condition like atrial fibrillation.
In those cases, adding a different type of blood thinner-like rivaroxaban-might be considered. But that’s rare and only done under strict supervision.
Final Decision: Who Gets What?
There’s no one-size-fits-all. Here’s how most Australian cardiologists decide today:
| Drug | Effectiveness | Bleeding Risk | Dosing | Best For | Avoid If |
|---|---|---|---|---|---|
| Prasugrel | Strongest clot prevention | High | Once daily | Young, healthy, high-risk patients with stents | Over 75, under 60 kg, history of stroke |
| Ticagrelor | Very strong, reduces death risk | Moderate | Twice daily | Most patients under 75, no stroke history | Severe breathing problems, cannot take twice daily |
| Clopidogrel | Moderate, unreliable in some | Lowest | Once daily | Older patients, low weight, history of bleeding or stroke | Poor metabolizer (confirmed by testing) |
If you’re under 75, weigh more than 60 kg, and have no history of stroke, ticagrelor is usually the best balance of safety and power. If you’re high-risk and can’t tolerate ticagrelor’s side effects, prasugrel is the next step. If you’re older, frail, or have had bleeding before-clopidogrel is still the safest bet.
What Should You Do?
Don’t switch drugs on your own. But do ask your doctor these questions:
- Am I a good candidate for prasugrel based on my age, weight, and history?
- Have you checked if clopidogrel is working for me?
- What are the bleeding risks for me personally?
- Can we try ticagrelor instead? What are the side effects I should watch for?
- Is there a reason we’re not using the most effective drug for my risk level?
Most patients don’t know their options. But you’re reading this because you care. That’s half the battle. The other half? Talking to your doctor with clear questions.
Is prasugrel better than clopidogrel?
Prasugrel works faster and more reliably than clopidogrel, reducing the risk of another heart attack by about 19% in high-risk patients. But it also increases the risk of serious bleeding by 50%. For younger, healthy patients with stents, prasugrel is stronger. For older or frail patients, clopidogrel is safer.
Can I switch from clopidogrel to prasugrel?
Yes, but only under medical supervision. Switching is common if clopidogrel isn’t working or if your risk level changes after a stent. Your doctor will stop clopidogrel and start prasugrel the next day. Never switch on your own-this can cause dangerous clotting or bleeding.
Why is ticagrelor preferred over prasugrel now?
Ticagrelor reduces overall death rates after a heart attack, not just clots. It also has a lower bleeding risk than prasugrel. While prasugrel blocks platelets more strongly, ticagrelor offers a better safety balance. Guidelines now recommend ticagrelor as first-line for most patients under 75 without a stroke history.
Does prasugrel cause shortness of breath?
No, shortness of breath is mainly linked to ticagrelor, affecting about 15% of users. Prasugrel doesn’t typically cause this side effect. If you’re on prasugrel and feel breathless, it could be a sign of another issue-like heart failure or lung disease-and should be checked immediately.
Can I take prasugrel if I’ve had a stroke before?
No. Prasugrel is contraindicated in patients with a history of stroke or transient ischemic attack (TIA). The risk of another stroke from bleeding is too high. Clopidogrel or ticagrelor may be used instead, depending on your overall risk.
Next Steps
If you’re on one of these drugs, make sure you know why. Ask for a copy of your bleeding risk score. Find out if your doctor has considered your weight, age, or past medical history when choosing your medication. Keep a list of side effects you notice-especially any bleeding or breathing issues. Bring it to your next appointment.
Don’t assume the drug you’re on is the best one. The right antiplatelet isn’t just about what works-it’s about what works for you.
Emil Tompkins
October 28, 2025 AT 19:28Prasugrel? More like Prasugrel-ly dangerous if you ask me
I had a cousin on it after his stent and he bled out from a nosebleed that wouldn't stop
Doctors act like these pills are magic bullets but they're just profit centers
Why do you think they push the expensive ones? Because insurance pays for it
My aunt was on clopidogrel for 7 years and never had another issue
They just want you scared enough to take the next thing
And don't get me started on ticagrelor and the breathing thing
Like oh yeah you're having a heart attack but also now you're gasping for air like you're drowning
It's all just corporate theater
They don't care if you live or die as long as you keep buying pills
Ask yourself: who benefits from you being on this drug for life?
Not you
Kevin Stone
October 29, 2025 AT 10:56It's not that complicated. If you're under 75, no stroke history, and not a walking hemorrhage - ticagrelor is the standard of care now
PLATO trial showed mortality benefit. Prasugrel didn't. That's it.
Stop clinging to outdated protocols because you're afraid of twice-daily dosing
And no, 'cost' isn't an excuse if you're in the US - if you're high risk, your insurer will cover it
Anyone still pushing clopidogrel as first-line in a young patient is practicing 2010 medicine
And yes, the breathing side effect is real - but it's not a heart attack
It's a side effect. You can manage it. You can't manage a second MI
Stop making this into a horror story. It's pharmacology, not horror fiction
Natalie Eippert
October 30, 2025 AT 08:23Let me tell you something about American medicine
We don't need to be copying European guidelines
Ticagrelor is expensive. Prasugrel is stronger. Clopidogrel is proven
Why are we abandoning what works for something that costs 8x more?
And don't even get me started on that 'breathing trouble' nonsense
It's just anxiety dressed up as a side effect
My brother took ticagrelor and complained about it - but he was a hypochondriac
Real Americans don't need fancy drugs. We need discipline, clean eating, and no smoking
But no - we'd rather take a pill and call it a day
And now they want us to take it twice a day? Ridiculous
Stick with clopidogrel. It's American-made. It's affordable. It's been around
Don't let Big Pharma scare you into buying the newest, shiniest toy
kendall miles
October 31, 2025 AT 00:23Did you know prasugrel was developed by a subsidiary of a company that also makes blood pressure monitors that were found to be inaccurate in 2018?
And ticagrelor? That's the same company that paid $1.2 billion in 2021 to settle lawsuits over misleading marketing
They're not trying to save lives
They're trying to create lifelong customers
And the bleeding risk? That's not an accident
It's a feature
Because when you bleed, you go back to the hospital
And then they sell you more drugs
And then they sell you stents
And then they sell you rehab
It's a closed loop
They want you dependent
They don't want you healthy
They want you on the treadmill
Ask yourself - who profits when you're sick?
Not your doctor
Not your family
It's the same people who told you cholesterol causes heart disease
And now they're telling you to take this
Think
Gary Fitsimmons
November 1, 2025 AT 23:44I just want to say - this is super important info
My dad was on clopidogrel and kept having mini-strokes
We got him tested - turns out he's a poor metabolizer
Switched him to ticagrelor and he's been fine for two years now
So if you're on clopidogrel and still having issues - don't just accept it
Ask for platelet testing
It's not expensive
And it could save your life
Don't be scared to ask questions
Your doctor wants you to be healthy too
Just speak up
luna dream
November 2, 2025 AT 23:37It's funny how we think drugs can fix what our culture broke
We eat sugar like it's oxygen, sit all day, stress out over emails, and then swallow a pill to undo it
Prasugrel, ticagrelor - they're just bandaids on a corpse
We're treating symptoms while ignoring the disease: modern life
What if the real solution isn't another drug… but a different way of living?
But no - we'd rather keep scrolling, eating, and taking pills
It's easier than change
And so we die quietly - with a prescription in our hand
Linda Patterson
November 4, 2025 AT 09:25Let’s be clear: prasugrel is not for the weak
It’s a high-risk, high-reward pharmacological intervention
And if you’re not a candidate, you shouldn’t be on it - period
But here’s the problem: primary care physicians are prescribing it like it’s ibuprofen
They don’t understand P2Y12 kinetics
They don’t know the TRITON-TIMI 38 inclusion criteria
And they certainly don’t check platelet reactivity
Ticagrelor’s reversibility? That’s not a bug - it’s a feature for surgical patients
And yes, the dyspnea is real - but it’s not hypoxia
It’s adenosine-mediated
And it’s manageable
If you’re not willing to do the due diligence - stick with clopidogrel
But don’t pretend you’re making an informed decision if you’re just following the latest trend
Cardiology isn’t fashion
Jen Taylor
November 4, 2025 AT 10:17Wow - this post was so clear and helpful
I’ve been on clopidogrel for 4 years after my stent and never thought to ask if it was working
Just assumed it was
But now I’m going to ask my cardiologist about platelet testing
And if I’m a poor metabolizer? I’ll switch - no hesitation
My grandma lived to 92 on aspirin alone - but I’m not her
I’m 58, diabetic, had a big heart attack - I need the strongest protection
And if ticagrelor means I have to take it twice a day? Fine
I’ll set phone alarms
It’s not a burden - it’s my lifeline
Thank you for explaining the bleeding risks too
I’ll keep an eye out for bruising
And I’ll never skip a dose again
You just saved me from a silent disaster
Shilah Lala
November 4, 2025 AT 22:47So let me get this straight - we have three drugs, all with side effects, and we're supposed to pick the one that makes us feel the least like a lab rat?
Prasugrel: bleed harder
Ticagrelor: breathe like you're underwater
Clopidogrel: maybe work, maybe not - good luck!
Wow. What a system
At least with the old days, you just got aspirin and a stern look
Now you get a 12-page pamphlet and a $40 monthly bill
Thanks, medicine
At least I can say I tried
Christy Tomerlin
November 5, 2025 AT 04:29Prasugrel is overkill for most
Ticagrelor is the sweet spot
Clopidogrel is for the frail
End of story
Stop overcomplicating it
And yes - if you're over 75, skip prasugrel
It's not a contest
It's survival