Fig. 1.Mechanism of action of oral P2Y-inhibitors. The
mechanism of action of oral P2Y-inhibitors consists of the blockage of the
platelet P2Y receptor, which is a 7-membrane-spanning receptor from the P2
family. The P2Y receptor is normally activated by the adenosine 5’
diphosphate (ADP) released from dense granules following platelet activation and
is coupled to an inhibitory G protein that inhibits adenylyl cyclase, translating
into the induction of platelet aggregation. The main role of the P2Y
receptor is to amplify platelet activation (also supported by signaling via the
glycoprotein IIb/IIIa receptor), which however requires the P2Y receptor
for the initiation phase. Different drugs can inhibit the P2Y receptor:
clopidogrel and prasugrel require a two- and one-step, respectively, hepatic
biotransformation to generate active metabolites that irreversibly inhibit the
P2Y receptor. On the other hand, ticagrelor is directly active (i.e., does
not require hepatic metabolism to exert its pharmacological activity, although
30% of its effects is attributed to a hepatic-derived metabolite) and reversibly
binds to the P2Y receptor. Abbreviations: 5-HT, 5-hydroxytryptamine;
5HT, 5-hydroxytryptamine receptor 2A; ADP, adenosine 5’ diphosphate; ATP,
adenosine triphosphate; C, clopidogrel; GPIIb/IIIa, glycoprotein IIb/IIIa; GP VI,
platelet glycoprotein VI; P, prasugrel; PAR, proteinase-activated receptor; T,
ticagrelor; TXA, thromboxane A; vWF, von Willebrand factor.