High On-Treatment Platelet Reactivity as a Risk Factor for Secondary Prevention After Coronary Stent Revascularization: A Landmark Analysis of the ARCTIC Study

Study Questions:

What is the clinical impact of individualizing antiplatelet therapy in patients undergoing primary percutaneous coronary intervention (PCI)?

Methods:

The authors reported a secondary analysis from the ARCTIC trial. In this trial, 2,440 patients were randomized before coronary stenting to a strategy of platelet function monitoring (VerifyNow P2Y12/aspirin point of care assay) with drug adjustment in suboptimal responders to antiplatelet therapy or to a conventional strategy without monitoring and without drug and/or dose changes. The authors reported a landmark analysis starting at the time of hospital discharge evaluating the primary endpoint of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization through 1 year.

Results:

There was no difference in the two arms in this analysis, with the primary endpoint occurring after discharge in 8.6% of patients in the monitoring arm and 7.9% in the conventional arm (hazard ratio, 1.105; 95% confidence interval, 0.835-1.461; p = 0.48). Stent thrombosis or urgent revascularization occurred in 4.4% and 4.5% in the monitoring and conventional arms, respectively (p = 0.99). Major bleeding event rates were 1.8% in the monitoring arm versus 2.8% in the conventional arm (p = 0.11), whereas major or minor bleeding event rates were 2.3% versus 3.4%, respectively (p = 0.10).

Conclusions:

The authors concluded that identification of platelet hyper-reactivity by platelet function testing to guide therapeutic choice did not reduce ischemic events in patients undergoing coronary stenting.

Perspective:

There is a large body of data that support worse outcomes in patients with high on-treatment platelet reactivity in patients undergoing PCI. Surprisingly, all the studies that have attempted to tailor antiplatelet therapy to platelet reactivity have failed to demonstrate any clinical benefit (e.g., GRAVITAS, ARCTIC, TRILOGY substudy, etc.). This study adds to the large body of data supporting a lack of role for platelet function testing to guide antiplatelet therapy for patients undergoing PCI.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Myocardial Infarction, Stroke, Platelet Aggregation Inhibitors, Platelet Function Tests, Drug-Eluting Stents, Ticlopidine, Risk Factors, Angioplasty, Balloon, Coronary, Percutaneous Coronary Intervention, Biological Markers, Secondary Prevention, Coronary Angiography, Troponin I, Thrombosis, Confidence Intervals, Hemorrhage


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