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Randomized Controlled Trial
. 2021 Sep;110(9):1493-1503.
doi: 10.1007/s00392-021-01866-3. Epub 2021 May 17.

Clopidogrel vs. prasugrel vs. ticagrelor in patients with acute myocardial infarction complicated by cardiogenic shock: a pooled IABP-SHOCK II and CULPRIT-SHOCK trial sub-analysis

Martin Orban #  1   2   3 , Jan Kleeberger #  4   5 , Taoufik Ouarrak  6 , Anne Freund  7 , Hans-Josef Feistritzer  7 , Georg Fuernau  8 , Tobias Geisler  9 , Kurt Huber  10 , Dariusz Dudek  11 , Marko Noc  12 , Gilles Montalescot  13 , Alexander Neumer  6 , Paul Haller  14 , Peter Clemmensen  14 , Uwe Zeymer  6 , Steffen Desch  7 , Steffen Massberg  4   5 , Steffen Schneider  6 , Holger Thiele #  7 , Jörg Hausleiter  4   5
Affiliations
Randomized Controlled Trial

Clopidogrel vs. prasugrel vs. ticagrelor in patients with acute myocardial infarction complicated by cardiogenic shock: a pooled IABP-SHOCK II and CULPRIT-SHOCK trial sub-analysis

Martin Orban et al. Clin Res Cardiol. 2021 Sep.

Abstract

Aims: The aim of this pooled sub-analysis of the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) and Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial was to compare the clinical outcome of patients with acute myocardial infarction complicated by cardiogenic shock treated either with clopidogrel or the newer, more potent ADP-receptor antagonists prasugrel or ticagrelor.

Methods and results: For the current analysis the primary endpoint was 1-year mortality and the secondary safety endpoint was moderate or severe bleedings until hospital discharge with respect to three different ADP-receptor antagonists. 856 patients were eligible for analysis. Of these, 507 patients (59.2%) received clopidogrel, 178 patients (20.8%) prasugrel and 171 patients (20.0%) ticagrelor as acute antiplatelet therapy. The adjusted rate of mortality after 1-year did not differ significantly between prasugrel and clopidogrel (hazard ratio [HR]: 0.81, 95% confidence interval [CI] 0.60-1.09, padj = 0.17) or between ticagrelor and clopidogrel treated patients (HR: 0.86, 95% CI 0.65-1.15, padj = 0.31). In-hospital bleeding events were significantly less frequent in patients treated with ticagrelor vs. clopidogrel (HR: 0.37, 95% CI 0.20 -0.69, padj = 0.002) and not significantly different in patients treated with prasugrel vs. clopidogrel (HR: 0.73, 95% CI 0.43 -1.24, padj = 0.24).

Conclusion: This pooled sub-analysis is the largest analysis on safety and efficacy of three oral ADP-receptor antagonists and shows that acute therapy with either clopidogrel, prasugrel or ticagrelor is no independent predictor of 1-year mortality. Treatment with ticagrelor seems independently associated with less in-hospital moderate and severe bleeding events compared to clopidogrel. This finding might be due to selection bias and should be interpreted with caution.

Keywords: ADP-receptor antagonists; Bleeding; Cardiogenic shock; Clopidogrel; Prasugrel; Ticagrelor.

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Conflict of interest statement

Martin Orban has received (directly or indirectly) speaker honoraria from Abbott Medical, AstraZeneca, Abiomed, Bayer vital, BIOTRONIK, Bristol-Myers Squibb, CytoSorbents, Daiichi Sankyo Deutschland, Edwards Lifesciences Services, Sedana Medical, outside the submitted work. Jörg Hausleiter received speaker honoraria and research support from Abbott Vascular and Edwards Lifesciences, outside the submitted work. Kurt Huber received lecture fees from AstraZeneca, Daiichi Sankyo and Sanofi Aventis, outside the submitted work. Peter Clemmensen has previously or currently been involved in research contracts, consulting, speakers bureau or received research and educational grants from: Abbott, Acarix, AstraZeneca, Aventis, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo, Eli-Lilly, Evolva, Fibrex, Janssen, Merck, Myogen, Medtronic, Mitsubishi Pharma, The Medicines Company, Nycomed, Organon, Pfizer, Pharmacia, Regado, Sanofi, Searle, Servier, Quantum. Tobias Geisler reports speaker honoraria from Astra Zeneca, Boehringer Ingelheim, Ferrer, and Pfizer; grants and honoraria from BayerHealthcare, BristolMyers Squibb, Daiichi Sankyo, Medtronic and Edwards Lifesciences and is supported by the German Research Foundation (DFG) – Project number 374031971 – TRR 240. The other authors declare no conflict of interests.

Figures

Fig. 1
Fig. 1
Study flow chart of the pooled sub-analysis on ADP-receptor antagonists in patients from the IABP-SHOCK II and CULPRIT-SHOCK trial. AMI acute myocardial infarction, PCI percutaneous coronary intervention
Fig. 2
Fig. 2
The Figure shows the survival curve during 1-year follow-up period in patients treated with clopidogrel (blue line), prasugrel (red line) or ticagrelor (green line)
Fig. 3
Fig. 3
The Figure shows the bleeding curve during 30-day follow-up period in patients treated with clopidogrel (blue line), prasugrel (red line) or ticagrelor (green line)
See this image and copyright information in PMC

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