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Effect of prasugrel pre-treatment strategy in patients undergoing percutaneous coronary intervention for NSTEMI: the
Gilles Montalescot1, Jean-Philippe Collet1, Patrick Ecollan2
1ACTION Study Group, Institut de Cardiologie, UPMC Université Paris 6, INSERM UMRS-1166 Paris, Centre Hospitalier Universitaire Pitié-Salpêtriėre (AP-HP), Paris, France.
Insights
Pre-treating non-ST-segment elevation myocardial infarction (NSTEMI) patients with prasugrel before percutaneous coronary intervention (PCI) showed no benefit and increased bleeding. Deferring prasugrel until after revascularization decisions is recommended for NSTEMI patients.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Dual antiplatelet therapy with aspirin and a P2Y12 antagonist is standard for 1 year post-percutaneous coronary intervention (PCI) for non-ST-segment elevation myocardial infarction (NSTEMI).
- Oral P2Y12 antagonists like ticagrelor and prasugrel are preferred over clopidogrel, but the optimal timing of administration relative to PCI remains unclear.
Purpose of the Study:
- To evaluate the efficacy and safety of pre-treatment with prasugrel before PCI in patients diagnosed with NSTEMI.
- To determine if early prasugrel administration reduces ischemic events or impacts thrombus burden compared to deferring treatment until PCI.
Main Methods:
- The randomized, double-blind ACCOAST trial enrolled 4,033 NSTEMI patients, with 68.7% undergoing PCI.
- 1,394 patients received pre-treatment with prasugrel (30-mg loading dose), while 1,376 received placebo; both groups received additional prasugrel doses at PCI.
- Primary efficacy endpoint was a composite of cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa bailout within 7 days. Thrombus presence was assessed via angiography.
Main Results:
- Pre-treatment with prasugrel did not significantly reduce the primary endpoint incidence (13.1% vs. 13.1%, p=0.93) and did not decrease ischemic events or mortality.
- Patients with angiographic thrombus had a 3-fold higher incidence of the primary endpoint.
- Pre-treatment significantly increased major bleeding (3-fold) and life-threatening bleeding (6-fold) without affecting thrombus presence or stent thrombosis.
Conclusions:
- Deferring prasugrel administration until after revascularization decisions are made is supported for NSTEMI patients undergoing angiography within 48 hours.
- Pre-treatment with prasugrel in NSTEMI patients undergoing PCI is not associated with improved ischemic outcomes but increases bleeding risk.
Background:
After percutaneous coronary intervention (PCI) for non-ST-segment elevation myocardial infarction (NSTEMI), treatment with a P2Y12 antagonist with aspirin is recommended for 1 year.
Objectives:
The oral P2Y12 antagonists ticagrelor and prasugrel have higher recommendations than clopidogrel, but it is unknown if administration before the start of PCI is beneficial.
Methods:
In the randomized, double-blind ACCOAST (A Comparison of prasugrel at the time of percutaneous Coronary intervention Or as pre-treatment At the time of diagnosis in patients with non-ST-segment elevation myocardial infarction) trial, 4,033 patients were diagnosed with NSTEMI and 68.7% underwent PCI; 1,394 received pre-treatment with prasugrel (30-mg loading dose), and 1,376 received placebo. At the time of PCI, patients who received pre-treatment with prasugrel received an additional 30-mg dose of prasugrel, and those who received placebo received a 60-mg loading dose of prasugrel. Primary efficacy was a composite of cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa bailout through 7 days from randomization. Investigators captured the presence of thrombus on initial angiography and during PCI.
Results:
The incidence of the primary endpoint through 7 days from randomization in the pre-treatment group versus the no pre-treatment group was 13.1% versus 13.1% (p = 0.93). Pre-treatment with prasugrel was not associated with decreases in any ischemic event, including total mortality. Patients with thrombus on angiography had a 3-fold higher incidence of the primary endpoint than patients without thrombus. There was no impact of pre-treatment with prasugrel on the presence of thrombus before PCI or on occurrence of stent thrombosis after PCI. There was a 3-fold increase in all non-coronary artery bypass graft Thrombolysis In Myocardial Infarction (TIMI) major bleeding and a 6-fold increase in non-coronary artery bypass graft life-threatening bleeding with pre-treatment with prasugrel; the same trends persisted in patients who had radial or femoral access even with use of a closure device.
Conclusions:
These findings support deferring treatment with prasugrel until a decision is made about revascularization in patients with NSTEMI undergoing angiography within 48 h of admission. (A Comparison of prasugrel at the time of percutaneous Coronary intervention Or as pre-treatment At the time of diagnosis in patients with non-ST-segment elevation myocardial infarction [ACCOAST]; NCT01015287).
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