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Personalized ADP-receptor inhibition strategy and outcomes following primary PCI for STEMI (PASTOR study)
Jussi Mikkelsson1, Tuomas Paana1, Aino Lepantalo2
1Heart Center, Satakunta Central Hospital, Pori, Finland.
Insights
For ST-elevation myocardial infarction (STEMI) patients, switching from clopidogrel to novel ADP receptor antagonists due to high platelet reactivity (HPR) did not alter major adverse cardiac events. Platelet function testing can guide antiplatelet therapy choices.
Area of Science:
- Cardiology
- Pharmacology
- Thrombosis
Background:
- Optimal antiplatelet therapy is crucial for ST-elevation myocardial infarction (STEMI) patients to prevent ischemic events.
- Potent oral antiplatelet agents increase bleeding risk, necessitating careful treatment selection.
- Investigating outcomes of switching antiplatelet therapy based on platelet reactivity is important.
Purpose of the Study:
- To compare outcomes in STEMI patients with high platelet reactivity (HPR) on clopidogrel who were switched to novel ADP receptor antagonists versus those with adequate response to clopidogrel.
- To evaluate the clinical utility of platelet function testing in guiding antiplatelet therapy selection post-STEMI.
Main Methods:
- Prospective cohort study (PASTOR) of 175 STEMI patients undergoing primary percutaneous coronary intervention (PCI).
- Patients received a 600 mg clopidogrel loading dose.
- VerifyNow P2Y12 testing assessed platelet reactivity the morning after PCI.
Main Results:
- 26.3% of patients (46/175) exhibited HPR (PRU>235) and were switched to novel ADP receptor antagonists.
- No significant difference in major adverse cardiac events (MACE) was observed between the clopidogrel group (7.0%) and the novel antagonist group (8.7%) during dual antiplatelet therapy (DAPT).
- Outcomes were similar between groups after discontinuation of DAPT.
Conclusions:
- STEMI patients treated with primary PCI who have adequate response to clopidogrel experience similar outcomes to those switched to novel ADP receptor antagonists due to HPR.
- Platelet reactivity testing is a valuable tool for guiding antiplatelet therapy choices in STEMI patients undergoing primary PCI.
Background:
Adequate antiplatelet therapy in patients with myocardial infarction with ST-elevation (STEMI) is vital in order to avoid ischemic complications. However, especially with the novel potent oral drugs, bleeding is a major concern. We aimed to investigate whether STEMI patients switched to novel ADP receptor inhibitors due to high platelet reactivity (HPR) on clopidogrel have similar outcomes compared to patients with adequate response to clopidogrel.
Methods:
A prospective cohort of 175 STEMI patients (mean age 62.3 years) undergoing primary PCI were included in the PASTOR study. Patients were loaded with 600 mg clopidogrel before the index PCI procedure. Bedside VerifyNow P2Y12 platelet function testing was performed the following morning.
Results:
46 patients (26.3%) were found to have HPR on clopidogrel (PRU>235) and were switched to novel ADP receptor antagonists. The remaining 129 patients were treated with clopidogrel. The mean duration of dual antiplatelet therapy (DAPT) was 6.7 months. Duration of entire follow-up of patients was approximately 2 years. Major adverse cardiac events (MACE) while patients were on DAPT occurred in 7.0% in the clopidogrel group compared to 8.7% in the novel ADP receptor antagonist group (p=0.70). No differences were observed between groups off-DAPT either.
Conclusions:
Following primary PCI for STEMI, patients with adequate response to clopidogrel show similar outcomes compared to patients switched to novel ADP receptor antagonists due to HPR on clopidogrel. Platelet reactivity testing can be used to guide the choice of antiplatelet therapy in patients with STEMI treated by primary PCI.
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