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KMID : 0368120220520040304
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Korean Circulation Journal
2022 Volume.52 No. 4 p.304 ~ p.319
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Prasugrel-based De-Escalation of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With STEMI
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Ki You-Jeong
Lee Bong-Ki
Park Kyung-Woo
Bae Jang-Whan
Hwang Do-Yeon
Kang Jee-Hoon
Han Jung-Kyu
Yang Han-Mo
Kang Hyun-Jae
Koo Bon-Kwon
Kim Dong-Bin
Chae In-Ho
Moon Keon-Woong
Park Hyun-Woong
Won Ki-Bum
Jeon Dong-Woon
Han Kyoo-Rok
Choi Si-Wan
Ryu Jae-Kean
Jeong Myung-Ho
Cha Kwang-Soo
Kim Hyo-Soo
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Abstract
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Background and Objectives: De-escalation of dual-antiplatelet therapy through dose reduction of prasugrel improved net adverse clinical events (NACEs) after acute coronary syndrome (ACS), mainly through the reduction of bleeding without an increase in ischemic outcomes. Whether the benefits of de-escalation are sustained in highly thrombotic conditions such as ST-elevation myocardial infarction (STEMI) is unknown. We aimed to assess the efficacy and safety of de-escalation therapy in patients with STEMI or non-ST-segment elevation ACS (NSTE-ACS).
Methods: This is a pre-specified subgroup analysis of the HOST-REDUCE-POLYTECH-ACS trial. ACS patients were randomized to prasugrel de-escalation (5 mg daily) or conventional dose (10 mg daily) at 1-month post-percutaneous coronary intervention. The primary endpoint was a NACE, defined as a composite of all-cause death, non-fatal myocardial infarction, stent thrombosis, clinically driven revascularization, stroke, and bleeding events of grade ≥2 Bleeding Academic Research Consortium (BARC) criteria at 1 year.
Results: Among 2,338 patients included in the randomization, 326 patients were diagnosed with STEMI. In patients with NSTE-ACS, the risk of the primary endpoint was significantly reduced with de-escalation (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.48?0.89; p=0.006 for de-escalation vs. conventional), mainly driven by a reduced bleeding. However, in those with STEMI, there was no difference in the occurrence of the primary outcome (HR, 1.04; 95% CI, 0.48?2.26; p=0.915; p for interaction=0.271).
Conclusions: Prasugrel dose de-escalation reduced the rate of NACE and bleeding, without increasing the rate of ischemic events in NSTE-ACS patients but not in STEMI patients.
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KEYWORD
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Acute coronary syndrome, Percutaneous coronary intervention, Prasugrel, ST elevation myocardial infarction, Non-ST elevated myocardial infarction
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