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Essentials    Procoagulant platelets can be detected using GSAO in human whole blood.  Stable coronary artery disease is associated with a heightened procoagulant platelet response.  Agonist‐induced procoagulant platelet response is not inhibited by aspirin alone.  Collagen plus thrombin induced procoagulant platelet response is partially resistant to clopidogrel.Summary   Background  Procoagulant platelets are a subset of highly activated platelets with a critical role in thrombin generation. Evaluation of their clinical utility in thrombotic disorders, such as coronary artery disease ( CAD ), has been thwarted by the lack of a sensitive and specific whole blood assay.    Objectives  We developed a novel assay, utilizing the cell death marker,  GSAO  [(4‐(N‐(S‐glutathionylacetyl)amino)phenylarsonous acid], and the platelet activation marker, P‐selectin, to identify procoagulant platelets in whole blood by flow cytometry.    Patients/Methods  Using this assay, we characterized the procoagulant platelet population in healthy controls and a cohort of patients undergoing elective coronary angiography.    Results  In patients with  CAD , compared with patients without  CAD , there was a heightened procoagulant platelet response to thrombin (25.2% vs. 12.2%), adenosine diphosphate ( ADP ) (7.8% vs. 2.7%) and thrombin plus collagen (27.2% vs. 18.3%). The heightened procoagulant platelet potential in  CAD  patients was not associated with other markers of platelet function, including aggregation, dense granule release and activation of α 2b β 3  integrin. Although dual antiplatelet therapy ( DAPT ) was associated with partial suppression of procoagulant platelets, this inhibitory effect on a patient level could not be predicted by aggregation response to  ADP  and was not fully suppressed by clopidogrel.    Conclusions  We report for the first time that procoagulant platelets can be efficiently detected in a few microliters of whole blood using the cell death marker,  GSAO , and the platelet activation marker, P‐selectin. A heightened procoagulant platelet response may provide insight into the thrombotic risk of  CAD  and help identify a novel target for antiplatelet therapies in  CAD .

Novel assay demonstrates that coronary artery disease patients have heightened procoagulant platelet response