COMPARison of pre-hospital CRUSHed vs. uncrushed Prasugrel tablets in patients with STEMI undergoing primary percutaneous coronary intervention - COMPARE CRUSH

Oct 14, 2020
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Author/Summarized by Author:
Dharam J. Kumbhani, MD, SM, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Maasstad Cardiovascular Research B.V. with unrestricted grants from Shanghai MicroPort Medical and Daiichi Sankyo
Date Presented:
10/14/2020
Date Published:
10/14/2020
Original Posted Date:
10/14/2020
References

Contribution To Literature:

In the COMPARE CRUSH trial, crushed prasugrel did not improve TIMI 3 flow at first angiography or complete ST-segment resolution at 1 hour post-PCI compared with integral prasugrel, both of which were administered as a 60 mg load in the ambulance prior to PPCI among patients with suspected STEMI.

Description:

The goal of the trial was to assess the efficacy of prehospital crushed vs. integral prasugrel among ST-segment elevation myocardial infarction (STEMI) patients being considered for primary percutaneous coronary intervention (PPCI).

Study Design

Eligible patients were randomized in a 1:1 fashion to either crushed (n = 369) or integral (n = 358) tablets of 60 mg prasugrel in the ambulance. They also received aspirin and heparin. Rapamycin target eluting stent (Firehawk MicroPort Medical, Shanghai, China) was used as the preferred stent.

  • Total screened: 1,669
  • Total number of enrollees: 727
  • Duration of follow-up: 48 hours
  • Mean patient age: 62 years
  • Percentage female: 23%

Inclusion criteria:

  • Suspected STEMI and symptom onset within 6 hours
  • Initially managed by a mobile emergency medical care unit
  • Plan for PPCI

Exclusion criteria:

  • History of a cerebral vascular accident
  • Recent gastrointestinal bleeding
  • Recent major surgery
  • Indication for chronic oral anticoagulation therapy
  • Dependent on hemodialysis
  • Unable to swallow oral medication
  • Presented with cardiogenic shock or cardiac arrest

Other salient features/characteristics:

  • Symptom onset to first medical contact: 58 minutes
  • Anterior MI: 38%
  • Use of glycoprotein inhibitors: 12%, opioids: 15%

Principal Findings:

The primary endpoint, Thrombolysis in Myocardial Infarction (TIMI) 3 flow in the infarct-related artery at first angiography, between crushed vs. integral prasugrel, was 31.0% vs. 32.7% (p = 0.64).

  • Complete ST-segment resolution 1-hour post-PPCI: 59.9% vs. 57.3% (p = 0.55)

Secondary outcomes for crushed vs. integral prasugrel:

  • High platelet reactivity at start of PCI (P2Y12 inhibitor reactivity units >208): 43.3% vs. 62.6% (p < 0.01)
  • Any bleeding: 3.3% vs. 3.9% (p = 0.63)
  • Stent thrombosis: 0.6% vs. 0.7% (p = 1.0)

Interpretation:

The results of this trial indicate that crushed prasugrel did not improve TIMI 3 flow at first angiography or complete ST-segment resolution at 1 hour post-PCI compared with integral prasugrel, both of which were administered as a 60 mg load in the ambulance prior to PPCI among patients with suspected STEMI. Platelet reactivity was lower in the crushed prasugrel arm, but this did not translate into lower stent thrombosis events or need for less frequent bailout glycoprotein inhibitor. The trial was underpowered for the latter two endpoints.

There was no use of cangrelor in this study, which showed a reduction in intraprocedural and early stent thrombosis events compared with clopidogrel in the CHAMPION PHOENIX trial. In the ATLANTIC trial, no difference in myocardial perfusion markers was noted with prehospital vs. in-hospital administration of ticagrelor, although there was a benefit noted in stent thrombosis.

References:

Vlachojannis G, Wilschut JM, Vogel R, et al. Effect of pre-hospital crushed prasugrel tablets in patients with STEMI planned for primary percutaneous coronary intervention: the randomized COMPARE CRUSH trial. Circulation 2020;Oct 14:[Epub ahead of print].

Presented by Dr. Georgios Vlachojannis at the Transcatheter Cardiovascular Therapeutics Virtual Meeting (TCT Connect), October 14, 2020.

Clinical Topics: Anticoagulation Management, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Aspirin, Coronary Angiography, Drug-Eluting Stents, Heparin, Percutaneous Coronary Intervention, Purinergic P2Y Receptor Antagonists, Purinergic P2Y Receptor Agonists, ST Elevation Myocardial Infarction, Stents, TCT20, Thrombosis, Transcatheter Cardiovascular Therapeutics


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