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Prasugrel-based De-Escalation of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With
You-Jeong Ki1, Bong Ki Lee2, Kyung Woo Park3
1Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
Insights
De-escalating prasugrel dosage after acute coronary syndrome (ACS) reduced net adverse clinical events (NACEs) in non-ST-elevation ACS (NSTE-ACS) patients by lowering bleeding risk. However, this benefit was not observed in ST-elevation myocardial infarction (STEMI) patients.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Dual-antiplatelet therapy (DAPT) de-escalation with reduced prasugrel dosage improved net adverse clinical events (NACEs) post-acute coronary syndrome (ACS), primarily by reducing bleeding without increasing ischemic events.
- The efficacy of DAPT de-escalation in highly thrombotic conditions like ST-elevation myocardial infarction (STEMI) remains unclear.
Purpose of the Study:
- To evaluate the efficacy and safety of prasugrel de-escalation therapy in patients with STEMI and non-ST-segment elevation ACS (NSTE-ACS).
Main Methods:
- A subgroup analysis of the HOST-REDUCE-POLYTECH-ACS trial randomized ACS patients to either prasugrel de-escalation (5 mg daily) or conventional dose (10 mg daily) one month post-percutaneous coronary intervention.
- The primary endpoint was NACE, a composite of death, non-fatal myocardial infarction, stent thrombosis, revascularization, stroke, and major bleeding (≥2 Bleeding Academic Research Consortium criteria) at one year.
Main Results:
- In NSTE-ACS patients, de-escalation significantly reduced NACE risk (HR, 0.65; 95% CI, 0.48-0.89), mainly due to decreased bleeding.
- In STEMI patients, no significant difference in NACE was observed between de-escalation and conventional dose groups (HR, 1.04; 95% CI, 0.48-2.26; p for interaction=0.271).
Conclusions:
- Prasugrel dose de-escalation effectively reduced NACE and bleeding in NSTE-ACS patients without increasing ischemic events.
- DAPT de-escalation with lower-dose prasugrel did not demonstrate similar benefits in STEMI patients, suggesting condition-specific treatment strategies are necessary.
Background And Objectives:
De-escalation of dual-antiplatelet therapy through dose reduction of prasugrel improved net adverse clinical events (NACEs) after acute coronary syndrome (ACS), mainly through the reduction of bleeding without an increase in ischemic outcomes. Whether the benefits of de-escalation are sustained in highly thrombotic conditions such as ST-elevation myocardial infarction (STEMI) is unknown. We aimed to assess the efficacy and safety of de-escalation therapy in patients with STEMI or non-ST-segment elevation ACS (NSTE-ACS).
Methods:
This is a pre-specified subgroup analysis of the HOST-REDUCE-POLYTECH-ACS trial. ACS patients were randomized to prasugrel de-escalation (5 mg daily) or conventional dose (10 mg daily) at 1-month post-percutaneous coronary intervention. The primary endpoint was a NACE, defined as a composite of all-cause death, non-fatal myocardial infarction, stent thrombosis, clinically driven revascularization, stroke, and bleeding events of grade ≥2 Bleeding Academic Research Consortium (BARC) criteria at 1 year.
Results:
Among 2,338 patients included in the randomization, 326 patients were diagnosed with STEMI. In patients with NSTE-ACS, the risk of the primary endpoint was significantly reduced with de-escalation (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.48-0.89; p=0.006 for de-escalation vs. conventional), mainly driven by a reduced bleeding. However, in those with STEMI, there was no difference in the occurrence of the primary outcome (HR, 1.04; 95% CI, 0.48-2.26; p=0.915; p for interaction=0.271).
Conclusions:
Prasugrel dose de-escalation reduced the rate of NACE and bleeding, without increasing the rate of ischemic events in NSTE-ACS patients but not in STEMI patients.
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