P4299Can prasugrel decrease the extent of periprocedural myocardial injury during elective PCI? - first report from the ONSIDE TEST Study

Abstract

Background: Periprocedural myocardial injury (PMI) occurring during percutaneous interventions (PCI) is associated with an increased risk of consecutive cardiovascular events. The evidence on safety and efficacy of more potent P2Y12 antagonists in reduction of PMI among patients undergoing elective PCI with inadequate response to clopidogrel is limited. Given that previous studies aimed at clinical outcomes comparison in stable coronary artery disease (SCAD) population have been stopped for futility, the approach to evaluate the impact of platelet testing‐based antiplatelet therapy modification on the surrogate endpoint of peak periprocedural troponin (Tn) elevation might allow to identify SCAD patients that could potentially benefit from intensified P2Y12 inhibition. Purpose: The aim of the study was to evaluate the impact of prasugrel on the incidence of PMI among SCAD individuals undergoing PCI with inadequate response to clopidogrel diagnosed by the point‐of‐care genotyping and platelet function testing (PFT). Methods: This is a subanalysis of a randomized, open‐labeled ONSIDE TEST study. SCAD patients undergoing elective PCI were randomized to one of the three study arms: 1) genotyping, 2) PFT and 3) control and evaluated by the point‐of‐care CYP2C19 allele genotyping and PFT with P2Y12 assay. Patients identified with inadequate response to clopidogrel by genotyping (group 1) or PFT P2Y12 assay (group 2) were switched to prasugrel two hours before PCI that was continued at a dose of 10 mg daily until therapy de‐escalation to clopidogrel at one week after the procedure. The incidence of PMI, defined as any Tn I elevation above the upper limit of norm at two, eight or 24 hours post PCI, was analyzed. The rates of death, myocardial infarction, repeated revascularization and bleeding were reported up to one year. Results: A total of 94 patients were analyzed. Of 25 (26.6%) patients identified with inadequate response to clopidogrel by either genotyping or PFT, 13 patients were switched to prasugrel while 12 patients continued dual antiplatelet therapy with clopidogrel. The incidence of PMI was numerically lower (61.54% vs. 91.67%, p=0.078) in the subset treated with prasugrel. There were reported one cardiac death and one non‐target vessel revascularization in the clopidogrel treated subgroup and one minor bleeding in the prasugrel group. Conclusions: Intensification of periprocedural dual antiplatelet therapy by prasugrel administration might potentially decrease the extent of periprocedural myocardial injury during elective PCI among patients with inadequate response to clopidogrel. Further studies are warranted to evaluate the safety and efficacy of the short‐term use of more potent antiplatelet agents in SCAD patients.