Assessment of prospective CYP2C19 genotype guided Dosing of AntiPlatelet Therapy in Percutaneous Coronary Intervention - ADAPT-PCI

Mar 10, 2018
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Author/Summarized by Author:
Dharam J. Kumbhani, MD, SM, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Date Presented:
03/10/2018
Date Updated:
03/10/2018
Original Posted Date:
03/10/2018
References

Contribution To Literature:

The use of point-of-care genotype testing for CYP2C19 significantly influences providers’ choice of P2Y12 inhibitor post-PCI.

Description:

The goal of the trial was to assess the impact of genotyping on P2Y12 prescription patterns following percutaneous coronary intervention (PCI).

Study Design

Patients undergoing PCI were randomized to CYP2C19 genotyping via buccal swab (n = 249) or usual care (n = 255).

  • Total number of enrollees: 504
  • Duration of follow-up: 48 months
  • Mean patient age: 63 years
  • Percentage female: 27%

Inclusion criteria:

  • Age ≥18 and ≤80 years
  • PCI with stent implantation

Exclusion criteria:

  • Need for imminent surgery
  • History of intracranial hemorrhage, stroke
  • Active bleeding
  • Need for long-term anticoagulation
  • Study staff unavailable to conduct randomization or genotyping

Other salient features/characteristics:

  • White 78%, black 20%
  • Acute coronary syndrome: 50%
  • Prior clopidogrel use: 33%
  • Genotype CYP2C19 frequency: *1/*1: 34%, *1/*2: 20%, *2/*17: 5%, *2/*2: 3%

Principal Findings:

The primary outcome, prescription of ticagrelor or prasugrel, among genotyped arm vs. usual care, was 30% vs. 21%, p = 0.03. Among loss of function carriers, it was 53% vs. 21%, p < 0.01.

Secondary outcomes (for ticagrelor vs. prasugrel):

  • Major adverse cardiac events: 13.7% vs. 10.2%, p = 0.27
  • Bleeding Academic Research Consortium (BARC) 3 or 5: 2.4% vs. 3.1%, p = 1.0

Interpretation:

The results of this trial indicate that the use of point-of-care genotype testing for CYP2C19 significantly influenced providers’ choice of P2Y12 inhibitor post-PCI. Nearly one half of all patients with loss-of-function mutation (suggestive of intermediate or poor metabolizer of clopidogrel) were prescribed either prasugrel or ticagrelor.

This is a small but interesting trial, which suggests that point-of-care testing can influence prescription behaviors. Unfortunately, other larger trials have shown that tailored P2Y12 inhibitor use does not affect clinical outcomes.

References:

Presented by Dr. Sony Tuteja at the American College of Cardiology Annual Scientific Session (ACC 2018), Orlando, FL, March 10, 2018.

Keywords: ACC18, ACC Annual Scientific Session, Acute Coronary Syndrome, Adenosine, Genotype, Hemorrhage, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Point-of-Care Systems, Stents


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