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Interval From Initiation of Prasugrel to Coronary Angiography
Study Questions:
What is the effect of pretreatment duration with prasugrel (time from randomization to angiography) on outcomes?
Methods:
The investigators conducted a prespecified analysis of the ACCOAST (A Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST Elevation Myocardial Infarction) trial. Within the 4,033 patients randomized in the ACCOAST trial, pretreatment duration was available in 4,001 patients (99.2%). The population of the trial was divided into quartiles of pretreatment duration (0.1-2.5 hours, 2.5-3.9 hours, 3.9-13.6 hours, and >13.6 hours) with an evaluation of the primary efficacy endpoint of cardiovascular death, myocardial infarction (MI), stroke, urgent revascularization, or glycoprotein IIb/IIIa inhibitor bailout use. Secondary efficacy outcomes including cardiovascular death, MI, or stroke; all-cause death; stent thrombosis and safety outcomes (all coronary artery bypass grafting [CABG]; or non-CABG TIMI [Thrombolysis In Myocardial Infarction] major bleeding) were also evaluated at 7 days. The hypothesis that the drug effect on primary efficacy or safety endpoints may be different accordingwashas been tested by the interaction between factor treatment and time categorized by quartiles in a Cox model of survival analysis.
Results:
The primary efficacy outcome of cardiovascular death, MI, stroke, urgent revascularization, or glycoprotein IIb/IIIa inhibitor bailout use did not differ between the quartiles of pretreatment duration in the trial population (p = 0.17 for interaction). None of the secondary efficacy outcomes were found to be dependent on pretreatment duration. The safety outcome of all CABG or non-CABG TIMI major bleeding did not differ between the quartiles of pretreatment duration (p = 0.37 for interaction).
Conclusions:
The authors concluded that in non–ST-segment elevation MI (NSTEMI) patients, the excess risk of bleeding and the absence of ischemic benefit were consistent across the quartiles of increasing duration of prasugrel pretreatment implying no benefit with longer pretreatment.
Perspective:
This study reports that in NSTEMI patients managed invasively, a longer duration of prasugrel pretreatment over a period of 48 hours before catheterization has no effect on ischemic outcomes. It appears that in patients with NSTE-acute coronary syndrome (ACS), addition of the P2Y12 inhibitor prasugrel to aspirin and anticoagulation increases major bleeding without improving ischemic risk regardless of the interval between administration and coronary angiography. Future studies are indicated to compare the safety and efficacy of fixed pretreatment regimens with administration of a rapidly acting P2Y12 inhibitor after determination of coronary anatomy in patients with NSTE-ACS to assess benefits of pretreatment, if any.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Aspirin, Catheterization, Coronary Angiography, Coronary Artery Bypass, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Glycoprotein GPIIb-IIIa Complex, Secondary Prevention, Stents, Stroke, Thrombosis, Treatment Outcome
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