1
|
Baber U, Chandrasekhar J, Sartori S, Aquino M, Kini AS, Kapadia S, Weintraub W, Muhlestein JB, Vogel B, Faggioni M, Farhan S, Weiss S, Strauss C, Toma C, DeFranco A, Baker BA, Keller S, Effron MB, Henry TD, Rao S, Pocock S, Dangas G, Mehran R. Associations Between Chronic Kidney Disease and Outcomes With Use of Prasugrel Versus Clopidogrel in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Report From the PROMETHEUS Study. JACC Cardiovasc Interv 2017; 10:2017-2025. [PMID: 28780028 DOI: 10.1016/j.jcin.2017.02.047] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/09/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study sought to compare clinical outcomes in a contemporary acute coronary syndrome (ACS) percutaneous coronary intervention (PCI) cohort stratified by chronic kidney disease (CKD) status. BACKGROUND Patients with CKD exhibit high risks for both thrombotic and bleeding events, thus complicating decision making regarding antiplatelet therapy in the setting of ACS. METHODS The PROMETHEUS study was a multicenter observational study comparing outcomes with prasugrel versus clopidogrel in ACS PCI patients. Major adverse cardiac events (MACE) at 90 days and at 1 year were defined as a composite of death, myocardial infarction, stroke, or unplanned revascularization. Clinically significant bleeding was defined as bleeding requiring transfusion or hospitalization. Cox regression multivariable analysis was performed for adjusted associations between CKD status and clinical outcomes. Hazard ratios for prasugrel versus clopidogrel treatment were generated using propensity score stratification. RESULTS The total cohort included 19,832 patients, 28.3% with and 71.7% without CKD. CKD patients were older with greater comorbidities including diabetes and multivessel disease. Prasugrel was less often prescribed to CKD versus non-CKD patients (11.0% vs. 24.0%, respectively; p < 0.001). At 1 year, CKD was associated with higher adjusted risk of MACE (1.27; 95% confidence interval: 1.18 to 1.37) and bleeding (1.46; 95% confidence interval: 1.24 to 1.73). Although unadjusted rates of 1-year MACE were lower with prasugrel versus clopidogrel in both CKD (18.3% vs. 26.5%; p < 0.001) and non-CKD (10.9% vs. 17.9%; p < 0.001) patients, associations were attenuated after propensity stratification. Similarly, unadjusted differences in 1-year bleeding with prasugrel versus clopidogrel (6.0% vs. 7.4%; p = 0.18 in CKD patients; 2.6% vs. 3.5%; p = 0.008 in non-CKD patients) were not significant after propensity score adjustment. CONCLUSIONS Although risks for 1-year MACE were significantly higher in ACS PCI patients with versus without CKD, prasugrel use was 50% lower in patients with renal impairment. Irrespective of CKD status, outcomes associated with prasugrel use were not significant after propensity adjustment. These data highlight the need for randomized studies evaluating the optimal antiplatelet therapy in CKD patients with ACS.
Collapse
Affiliation(s)
- Usman Baber
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jaya Chandrasekhar
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Melissa Aquino
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Samir Kapadia
- Division of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - William Weintraub
- Division of Cardiology, Christiana Care Health System, Newark, Delaware
| | | | - Birgit Vogel
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michela Faggioni
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Serdar Farhan
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sandra Weiss
- Division of Cardiology, Christiana Care Health System, Newark, Delaware
| | - Craig Strauss
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anthony DeFranco
- Division of Cardiology, Aurora Cardiovascular Services, Milwaukee, Wisconsin
| | | | | | - Mark B Effron
- Eli Lilly and Company, Indianapolis, Indiana; Division of Cardiology, John Ochsner Heart and Vascular Center, Ochsner Medical Center, New Orleans, Louisiana
| | - Timothy D Henry
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Sunil Rao
- Division of Cardiology, Duke University, Durham, North Carolina
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- Division of Cardiology, Mount Sinai Hospital, New York, New York
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.
| |
Collapse
|