Angiographic and platelet reactivity outcomes with prasugrel 60 mg pretreatment and clopidogrel 600 mg pretreatment in primary percutaneous coronary intervention

Upstream clopidogrel, prasugrel, or ticagrelor for patients treated with primary angioplasty: Results of an angiographic randomized pilot study

OBJETIVES

The main objective of the present randomized pilot study was to explore the effects of upstream prasugrel or ticagrelor or clopidogrel for patients with ST-segment-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

BACKGROUND

Administration of clopidogrel "as soon as possible" has been advocated for STEMI. Pretreatment with prasugrel and ticagrelor may improve reperfusion. Currently, the angiographic effects of upstream administration of these agents are poorly understood.

METHODS

A total of 132 patients with STEMI within the first 12 hr of chest pain referred to primary angioplasty were randomized to upstream clopidogrel (600 mg), prasugrel (60 mg), or ticagrelor (180 mg) while still in the emergency room. All patients underwent protocol-mandated thrombus aspiration.

RESULTS

Macroscopic thrombus material was retrieved in 79.5% of the clopidogrel group, 65.9% of the prasugrel group, and 54.3% of the ticagrelor group (P = 0.041). At baseline angiography, large thrombus burden was 97.7% vs. 87.8% vs. 80.4% in the clopidogrel, prasugrel, and ticagrelor groups, respectively (P = 0.036). Also, at baseline, 97.7% presented with an occluded target vessel in the clopidogrel group, 87.8% in the prasugrel group and 78.3% in the ticagrelor group (P = 0.019). At the end of the procedure, the percentages of patients with combined TIMI grade III flow and myocardial blush grade III were 52.3% for clopidogrel, 80.5% for prasugrel, and 67.4% for ticagrelor (P = 0.022).

CONCLUSIONS

In patients with STEMI undergoing primary PCI within 12 hr, upstream clopidogrel, prasugrel or ticagrelor have varying angiographic findings, with a trend toward better results for the latter two agents. © 2015 Wiley Periodicals, Inc.

Effects of prasugrel pretreatment on angiographic myocardial perfusion parameters in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVE

Prasugrel is a third-generation thienopyridine, with significant pharmacodynamic and clinical advantages over clopidogrel. There are few data on the effects of prasugrel therapy, as compared with clopidogrel, in terms of perfusion during percutaneous coronary intervention (PCI), in patients with ST-elevation myocardial infarction (STEMI).

METHODS

A total of 128 patients with STEMI, pretreated with prasugrel 60 mg loading dose (mean age=55.9±9.1; 10.9% were women and 18.0% had diabetes), were compared with 128 propensity-matched patients pretreated with clopidogrel 600 mg (mean age=58.7±10.7; 10.2% were women and 19.5% had diabetes) for the primary endpoint of thrombolysis in myocardial infarction (TIMI) flow and myocardial blush grade at completion of the PCI. Secondary endpoints included the combined sum of major adverse events: death, reinfarction or target vessel revascularization at 1 year.

RESULTS

Mean TIMI flow grade pre-PCI was similar between the two groups (1.31±1.3 in the prasugrel group and 1.30±1.2 in the clopidogrel group, P=0.96). However, after intervention, it was higher in the prasugrel group (2.94±0.24 vs. 2.84±0.37, respectively, P=0.016), as was myocardial blush (2.70±0.76 vs. 2.31±0.52, respectively, P<0.001). The percentage of TIMI 3 after intervention was also higher in the prasugrel group (97.70 vs. 90.60%, P=0.02). The combined rate of major adverse events at 1 year (8.7 vs. 11.6%, P=0.11), as well as total mortality (3.1±5.6 vs. 4.7±9.1%, P=0.52), did not differ between the two groups.

CONCLUSION

In patients with STEMI undergoing primary PCI, pretreatment with prasugrel resulted in better angiographic perfusion results, as compared with pretreatment with clopidogrel.

Use, efficacy and safety of prasugrel in patients with ST segment elevation myocardial infarction scheduled for primary percutaneous coronary intervention in clinical practice. Results of the prospective ATACS-registry

BACKGROUND

Prasugrel compared to clopidogrel has been shown to improve outcome in patients with ST elevation myocardial infarction (STEMI) in the TRITON-TIMI 38 trial. Little is known about the use, efficacy and safety of prasugrel in patients with STEMI in clinical practice.

METHODS

We conducted a prospective registry including patients with STEMI scheduled for primary percutaneous coronary intervention (PCI). Between October 2009 and February 2013 a total of 3291 patients with STEMI receiving a loading dose of either clopidogrel or prasugrel were included in this analysis.

RESULTS

Prasugrel was predominantly used in patients <75 years, body weight >60 kg and those without prior stroke. In-hospital mortality was numerically lower in the prasugrel group (1.7% vs. 4.4%), as well as non-fatal reinfarction (0.2% vs. 0.5%), non-fatal stroke (0.1% vs. 0.3%) and major cardiac and cerebrovascular events (MACCE) (2.1% vs. 5.2%), while there was no difference in major bleeding complications (0.8% vs. 0.9%). In the multivariate analysis the MACCE-rate tended to be lower in prasugrel treated patients (odds ratio 0.71, 95% confidence intervals 0.42-1.08) but bleeding-rates tended to be higher.

CONCLUSIONS

In this real life experience in patients with STEMI scheduled for primary PCI, prasugrel was almost exclusively used in the label-recommended patient population and tended to be more effective but associated with more bleedings compared to clopidogrel. These results support the findings in the STEMI population in the randomized TRITON-TIMI 38 study.

Plaque characteristics and serum pregnancy-associated plasma protein A levels predict the no-reflow phenomenon after percutaneous coronary intervention

OBJECTIVES

To investigate the relationship between serum plasma pregnancy-associated plasma protein A (PAPP-A) and coronary plaque characteristics, and their prognostic value for coronary no-reflow after percutaneous coronary intervention (PCI).

METHODS

Patients with unstable angina undergoing PCI were divided into a normal reflow group and a no-reflow group after stent deployment. Coronary blood flow was measured angiographically; plaque components were detected by virtual histology intravascular ultrasound. Serum PAPP-A and high-sensitivity C-reactive protein (hsCRP) were measured before PCI. Cardiac troponin T (cTnT) was measured before and 24 h after PCI.

RESULTS

A total of 166 patients with unstable angina undergoing PCI were included: normal reflow group (n = 145) and no-reflow group (n = 21), after stent deployment. Baseline coronary blood flow was similar in the two groups. The no-reflow group had plaques with less-fibrotic tissue and a larger necrotic core, more thin-cap fibroatheromas and plaque ruptures, and higher serum PAPP-A, hsCRP and post-PCI cTnT levels than the normal reflow group. Serum PAPP-A was correlated negatively with plaque fibrotic area and positively with necrotic core area.

CONCLUSION

High serum PAPP-A and plaque lesions with a large necrotic core are associated with the no-reflow phenomenon after PCI, in patients with unstable angina.