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Switching from clopidogrel to prasugrel reduced ischemic events in ACS
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Ischemic events were reduced in patients with ACS by switching those with high platelet reactivity from clopidogrel to prasugrel, concluded results published in the Journal of the American College of Cardiology.
The aim of the single-center, prospective registry study was to assess whether prasugrel (Effient, Eli Lilly/Daiichi Sankyo) and high-dose clopidogrel administered based on platelet function testing have an effect on ACS in the PCI setting.
The analysis included 741 consecutive patients accrued during September 2011 to August 2012.
The investigators used the Multiplate device to measure platelet function 12 to 36 hours after intervention. Patients in the high platelet reactivity group — defined as >46U — crossed over to prasugrel or began therapy with high-dose clopidogrel. Those not in the high reactivity group continued therapy with 75 mg clopidogrel.
There were 219 patients in the high platelet reactivity group.
Prasugrel was associated with significantly greater platelet inhibitory capabilities than high-dose clopidogrel despite decreases in platelet reactivity after treatment adjustments in the high reactivity group (P<.0001).
Risk for all-cause mortality, MI, stent thrombosis or stroke at 1 year was significantly higher in the high-dose clopidogrel group than in the cohort of patients without high platelet reactivity (HR=2.27; 95% CI, 1.45-3.55; P<.0001). Also at 1 year, patients who switched to prasugrel had similar rates of these outcomes as patients without high platelet reactivity (HR=0.90; 95% CI, 0.44-1.81; P=.76).
High-dose clopidogrel also was associated with higher rates of BARC type 3/5 bleeding (HR=2.09; 95% CI, 1.05-4.17; P=.04). However, patients who were switched to prasugrel did not experience this bleeding outcome (HR=0.45; 95% CI, 0.11-1.91; P=.28).
Results from a multivariable model suggested that high platelet reactivity with high-dose clopidogrel independently predicted the composite endpoint of ischemic outcomes (HR=1.90; 1.17-3.08; P=.01). High platelet reactivity with prasugrel did not predict this outcome, according to the results.
“Switching ACS patients with [high platelet reactivity] to prasugrel reduces thrombotic and bleeding events to a level similar to those without [high platelet reactivity],” the researchers concluded. “However, using high-dose clopidogrel results in higher risk for both thrombotic and bleeding complications.”
Disclosure: The researchers report financial disclosures with companies including Abbott Vascular, AstraZeneca, Bayer, Eli Lilly/Daiichi Sankyo, Krka, Pfizer, Roche and Verum Diagnostica.
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