TCT-105: Prevalence of prasugrel use and associations between type of acute coronary syndrome and 1-year clinical outcomes
Rafique A, Chandrasekhar J, Baber U, et al. TCT-105 Prevalence of prasugrel use and associations between type of acute coronary syndrome and 1-year clinical outcomes. Journal of the American College of Cardiology. 2016;68(18). doi:10.1016/j.jacc.2016.09.349.
Prasugrel is a potent antiplatelet agent with limited uptake due to bleeding concerns. Comparison of clinical outcomes by type of acute coronary syndrome (ACS) can guide treatment strategies. We compared the associations between prasugrel or clopidogrel use for all clinical outcomes by type and severity of ACS.
The PROMETHEUS study was a multicenter observational study of 19,913 ACS patients undergoing percutaneous coronary intervention (PCI). The primary endpoint was 90-day major adverse cardiovascular events (MACE), composite of death, myocardial infarction, stroke or unplanned revascularization. The safety endpoint was bleeding requiring hospitalization. Hazard ratios were generated using Cox regression for prasugrel versus clopidogrel and stratified by the propensity to receive prasugrel.
The study cohort included 3285 (16%) patients with STEMI, 5412 (27%) patients with NSTEMI and 11216 (56%) patients with unstable angina (UA). There were marked differences in baseline characteristics between the groups. STEMI patients were more likely to be smokers but had a lower prevalence of comorbidities, multivessel or complex disease compared to other ACS patients. Despite these differences, the prevalence of prasugrel use at discharge was highest in STEMI and lowest in UA patients (27 vs 22 vs 19% p < 0.0001). The incidence of MACE at all time points was greatest in STEMI followed by NSTEMI and UA. Unadjusted, prasugrel was associated with lower MACE than clopidogrel in all groups (p < 0.0001). The propensity score adjusted outcomes for MACE and bleeding are presented in the Figure .
STEMI patients present with fewer comorbidities than patients with other ACS types. Despite this, prasugrel compared to clopidogrel use was associated with lower early MACE outcomes in STEMI. Notwithstanding, only one-third of STEMI patients received prasugrel treatment.