The combination of clopidogrel with a statin can be pre- scribed safely on the basis of a secondary analysis of the CHARISMA trial in 10 078 patients with cardiovascular disease or multiple high-risk coronary risk factors.743 There was no difference in the composite endpoint of MI, stroke, or cardiovascular death between the agents, independent of the metabolism pathway of the statin. Clopidogrel requires a loading dose to accelerate the onset, intensity, and consisten- cy of inhibition.744,745 Prasugrel is a third-generation thienopyridine that has more potent antiplatelet effects and is associated with less interpatient variability in response than clopidogrel. In TRITON-TIMI (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel Thrombolysis In Myocardial Infarction) 38, there was a 19% reduction in RR of the primary efficacy endpoint (cardiovas- cular death, nonfatal MI, or nonfatal stroke) but an increased risk of bleeding with prasugrel compared with clopidogrel in ACS patients scheduled for percutaneous revasculariza- tion.746 Clinical trials evaluating prasugrel in patients with SIHD have not been conducted. It has not been tested or approved for use in patients with SIHD. Ticagrelor is a newly approved agent that has been shown to be beneficial in patients with ACS but has not been tested in patients with Ticlopidine is a thienopyridine derivative that also inhibits platelet aggregation but compares less favorably to clopi- dogrel as an alternative to aspirin, because it has limited evidence for cardiovascular event reduction among patients with SIHD and an associated risk of blood dyscrasias.720,721 For these reasons, its use is quite limited for secondary prevention among patients with SIHD. The pyrimido-pyrimidine derivative, dipyridamole, pos- sesses antiplatelet effects but does not have a proven role in patients with SIHD. 