Patients should be counseled on the need for and risks of DAPT before stent implantation, especially DES implantation, and alternative therapies pursued (BMS or balloon angioplasty) if they are unwilling or unable to comply with the recommended duration of DAPT. The efficacy of clopidogrel pretreatment remains contro- versial. Although some studies have suggested that pretreat- ment with clopidogrel is associated with decreased platelet aggregation and a significantly lower incidence of periproce- dural MI after elective PCI, others have suggested no benefit to pretreatment compared with administration of the drug in the catheterization laboratory.572,581,582 When prasugrel was compared with clopidogrel in patients with ACS in TRITON TIMI 38 (Trial to Assess Improve- ment in Therapeutic Outcomes by Optimizing Platelet Inhi- bition with Prasugrel Thrombolysis In Myocardial Infarc- tion), prasugrel was associated with a significant 2.2% reduction in absolute risk and a 19% reduction in relative risk in the composite endpoint of cardiovascular death, nonfatal MI, or nonfatal stroke, and a significant increase in the rate of TIMI major hemorrhage (1.8% versus 2.4%).567 Prasugrel is contraindicated in patients with a history of transient ische- mic attack or stroke. Patients weighing 60 kg have an increased risk of bleeding on the 10 mg daily maintenance dose. The package insert suggests that consideration should be given to lowering the maintenance dose to 5 mg daily, although the effectiveness and safety of the 5-mg dose has not been studied. Prasugrel is not recommended for patients 75 years of age because of the increased risk of fatal and intracranial bleeding and lack of benefit, except in patients with diabetes or a history of prior MI. Prasugrel should not be started in patients likely to undergo urgent CABG. 