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Prehospital Adenosine Diphosphate Receptor Blocker Use, Culprit Artery Flow, and Mortality in STEMI: The MADDEC Study
Markus Hautamäki1,2, Leo-Pekka Lyytikäinen3,4,5, Markku Eskola3,4
1Faculty of Medicine and Health Technology, University of Tampere, Arvo Building, Arvo Ylpön Katu 34, 33520, Tampere, Finland. markus.hautamaki@tuni.fi.
Insights
Newer adenosine diphosphate (ADP) receptor blockers, ticagrelor and prasugrel, significantly reduced acute mortality and improved artery flow in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) compared to clopidogrel.
Area of Science:
- Cardiology
- Pharmacology
- Interventional Cardiology
Background:
- Acute coronary syndrome (ACS) management often involves adenosine diphosphate (ADP) receptor blockers.
- Ticagrelor and prasugrel are newer ADP receptor blockers with demonstrated long-term superiority over clopidogrel in ACS.
- The acute performance of these agents during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) requires evaluation.
Purpose of the Study:
- To compare the acute performance of ticagrelor and prasugrel versus clopidogrel in STEMI patients undergoing primary PCI.
- To assess the impact of prehospital loading with these ADP receptor blockers on early outcomes.
Main Methods:
- Retrospective analysis of a single-center registry (n=3218) of STEMI patients undergoing primary PCI.
- Patients were treated with clopidogrel (2007-2010), prasugrel (2011-2014), or ticagrelor (2014-2020) during consecutive periods.
- Risk factor-adjusted multivariate logistic regression was used to compare 3- and 7-day mortality and culprit artery flow before and after PCI.
Main Results:
- Ticagrelor or prasugrel use was associated with improved culprit artery flow before PCI (OR 1.21, p=0.022) compared to clopidogrel.
- Use of newer agents was linked to significantly lower 3-day (OR 0.66, p=0.025) and 7-day mortality (OR 0.71, p=0.039).
- The mortality benefit was more pronounced in patients with shorter treatment delays.
Conclusions:
- Newer ADP receptor blockers (ticagrelor, prasugrel) demonstrate superior acute performance compared to clopidogrel in STEMI patients undergoing primary PCI.
- No significant differences were observed between ticagrelor and prasugrel in acute outcomes.
- Potential unmeasured confounding factors related to evolving cardiac care and population changes should be considered.
Background And Objective:
The newer adenosine diphosphate (ADP) receptor blockers ticagrelor and prasugrel are superior to clopidogrel in the long-term management of acute coronary syndrome (ACS). We evaluated the acute performance (prehospital loading) of these ADP receptor blockers in a primary percutaneous coronary intervention (PCI) for an ST-elevation myocardial infarction (STEMI).
Methods:
In a retrospective, single-center registry study, data on all STEMI patients admitted for their first primary PCI between January 2007 and April 2020 were analyzed (n = 3218). The three ADP receptor blockers were mainly used during consecutive periods (clopidogrel 2007-2010, prasugrel 2011-2014, and ticagrelor 2014-2020), and were compared with risk factor-adjusted multivariate logistic regression for acute 3- and 7-day mortality and culprit artery flow before and after PCI.
Results:
Of the 3218 total patients, 47.6% (n = 1532) were treated with ticagrelor, 22.1% (n = 711) were treated with prasugrel, and 30.3% (n = 975) were treated with clopidogrel. The use of ticagrelor or prasugrel as opposed to clopidogrel was associated with better culprit artery flow before PCI (odds ratio [OR] 1.21 for moderate or good flow, 95% confidence interval [CI] 1.03-1.42, p = 0.022), as well as lower acute mortality (OR 0.66 for 3-day mortality, 95% CI 0.46-0.95, p = 0.025; and OR 0.71 for 7-day mortality, 95% CI 0.52-0.98, p = 0.039). The results in regard to acute mortality were highlighted among patients with short treatment delays (disappearing with longer treatment delays; p < 0.05 for interaction).
Conclusions:
The newer ADP receptor blockers are associated with lower mortality and better culprit artery flow at presentation when compared with clopidogrel. There are no significant differences between the two newer drugs. As the drugs were mainly used during three consecutive periods, unmeasured confounding related to the development of cardiac care and changes in the population may contribute to the results.
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