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Observational Study
. 2018 Mar;34(3):319-329.
doi: 10.1016/j.cjca.2017.12.023. Epub 2017 Dec 27.

Associations Between Complex PCI and Prasugrel or Clopidogrel Use in Patients With Acute Coronary Syndrome Who Undergo PCI: From the PROMETHEUS Study

Jaya Chandrasekhar  1 , Usman Baber  1 , Samantha Sartori  1 , Melissa Aquino  1 , Annapoorna S Kini  2 , Sunil Rao  3 , William Weintraub  4 , Timothy D Henry  5 , Serdar Farhan  1 , Birgit Vogel  1 , Sabato Sorrentino  1 , Zhen Ge  1 , Samir Kapadia  6 , Joseph B Muhlestein  7 , Sandra Weiss  4 , Craig Strauss  8 , Catalin Toma  9 , Anthony DeFranco  10 , Mark B Effron  11 , Stuart Keller  12 , Brian A Baker  13 , Stuart Pocock  14 , George Dangas  1 , Roxana Mehran  15
Affiliations
Observational Study

Associations Between Complex PCI and Prasugrel or Clopidogrel Use in Patients With Acute Coronary Syndrome Who Undergo PCI: From the PROMETHEUS Study

Jaya Chandrasekhar et al. Can J Cardiol. 2018 Mar.

Abstract

Background: Potent P2Y12 inhibitors might offer enhanced benefit against thrombotic events in complex percutaneous coronary intervention (PCI). We examined prasugrel use and outcomes according to PCI complexity, as well as analyzing treatment effects according to thienopyridine type.

Methods: PROMETHEUS was a multicentre observational study that compared clopidogrel vs prasugrel in acute coronary syndrome patients who underwent PCI (n = 19,914). Complex PCI was defined as PCI of the left main, bifurcation lesion, moderate-severely calcified lesion, or total stent length ≥ 30 mm. Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke, or unplanned revascularization. Outcomes were adjusted using multivariable Cox regression for effect of PCI complexity and propensity-stratified analysis for effect of thienopyridine type.

Results: The study cohort included 48.9% (n = 9735) complex and 51.1% (n = 10,179) noncomplex patients. Second generation drug-eluting stents were used in 70.1% complex and 66.2% noncomplex PCI patients (P < 0.0001). Complex PCI was associated with greater adjusted risk of 1-year MACE (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.20-1.39; P < 0.001). Prasugrel was prescribed in 20.7% of complex and 20.1% of noncomplex PCI patients (P = 0.30). Compared with clopidogrel, prasugrel significantly decreased adjusted risk for 1-year MACE in complex PCI (HR, 0.79; 95% CI, 0.68-0.92) but not noncomplex PCI (HR, 0.91; 95% CI, 0.77-1.08), albeit there was no evidence of interaction (P interaction = 0.281).

Conclusions: Despite the use of contemporary techniques, acute coronary syndrome patients who undergo complex PCI had significantly higher rates of 1-year MACE. Adjusted magnitude of treatment effects with prasugrel vs clopidogrel were consistent in complex and noncomplex PCI without evidence of interaction.

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