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Can prasugrel decrease the extent of periprocedural myocardial injury during elective percutaneous coronary
Insights
Switching to prasugrel may reduce periprocedural myocardial injury in patients with poor response to clopidogrel during percutaneous coronary intervention (PCI). This guided therapy shows potential for improved cardiovascular event risk reduction.
Area of Science:
- Cardiology
- Pharmacology
- Genetics
Background:
- Periprocedural myocardial injury increases cardiovascular event risk.
- Limited data exists on potent P2Y12 antagonists for patients with inadequate clopidogrel response.
- Elective percutaneous coronary intervention (PCI) requires effective antiplatelet strategies.
Purpose of the Study:
- To assess prasugrel's impact on periprocedural myocardial injury in PCI patients.
- To evaluate patients with inadequate response to clopidogrel, identified by genotyping and platelet function testing (PFT).
- To determine if guided antiplatelet therapy improves outcomes.
Main Methods:
- Interim analysis of the randomized ONSIDE TEST study.
- Patients randomized to genotyping, PFT, or control arms.
- Poor clopidogrel responders (via CYP2C19 genotyping or PFT) were switched to prasugrel (60 mg) before PCI.
Main Results:
- 26.6% of patients (25/94) showed inadequate response to clopidogrel.
- Prasugrel use in poor responders trended towards lower myocardial injury (61.5% vs. 91.7%).
- No significant difference in overall myocardial injury rates across initial study arms.
Conclusions:
- Guided early administration of prasugrel may reduce periprocedural myocardial injury.
- This strategy is particularly relevant for patients with stable coronary artery disease undergoing PCI.
- Personalized antiplatelet therapy based on genetic and functional testing shows promise.
Abstract:
INTRODUCTION Periprocedural myocardial injury may be associated with an increased risk of cardiovascular events. There is limited evidence on the safety and efficacy of more potent P2Y12 antagonists in the reduction of the incidence of periprocedural myocardial injury among patients undergoing elective percutaneous coronary intervention (PCI) with inadequate response to clopidogrel. OBJECTIVES The aim of the study was to evaluate the impact of prasugrel on the incidence of periprocedural myocardial injury among patients undergoing elective PCI with inadequate response to clopidogrel, diagnosed by point‑of‑care genotyping and platelet function testing (PFT). PATIENTS AND METHODS This was a prespecified interim analysis of the randomized, open‑label ONSIDE TEST study. Patients with stable coronary artery disease (CAD) scheduled for PCI were randomized to one of the following study arms: 1) genotyping, 2) PFT, or 3) control, and evaluated by the CYP2C19 allele genotyping and PFT with the P2Y12 assay. Patients with poor response to clopidogrel by genotyping or PFT were loaded with 60 mg of prasugrel before PCI. The incidence of periprocedural myocardial injury was analyzed. RESULTS A total of 94 patients (genotyping, 34; PFT, 34; control, 26) were analyzed. Of the 25 patients (26.6%) with inadequate response to clopidogrel, 13 were switched to prasugrel while 12 continued dual antiplatelet therapy with clopidogrel. While similar rates of any periprocedural myocardial injury were found in the genotyping, PFG, and control arms (76.5%, 73.5%, and 73.1%, respectively), the incidence of periprocedural myocardial injury tended to be lower in the subset of patients with poor response to clopidogrel who were treated with prasugrel (61.5% vs 91.7%, P = 0.078). CONCLUSIONS Guided early prasugrel administration may decrease the extent of periprocedural myocardial injury during PCI in patients with stable CAD.
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