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. 2022 Apr;52(4):304-319.
doi: 10.4070/kcj.2021.0293. Epub 2021 Dec 21.

Prasugrel-based De-Escalation of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With STEMI

You-Jeong Ki #  1 , Bong Ki Lee #  2 , Kyung Woo Park  3 , Jang-Whan Bae  4 , Doyeon Hwang  1 , Jeehoon Kang  1 , Jung-Kyu Han  1 , Han-Mo Yang  1 , Hyun-Jae Kang  1 , Bon-Kwon Koo  1 , Dong-Bin Kim  5 , In-Ho Chae  6 , Keon-Woong Moon  7 , Hyun Woong Park  8 , Ki-Bum Won  9 , Dong Woon Jeon  10 , Kyoo-Rok Han  11 , Si Wan Choi  12 , Jae Kean Ryu  13 , Myung Ho Jeong  14 , Kwang Soo Cha  15 , Hyo-Soo Kim  1 ; HOST-RP-ACS investigators
Affiliations

Prasugrel-based De-Escalation of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With STEMI

You-Jeong Ki et al. Korean Circ J. 2022 Apr.

Erratum in

Abstract

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.

Keywords: Acute coronary syndrome; Non-ST elevated myocardial infarction; Percutaneous coronary intervention; Prasugrel; ST elevation myocardial infarction.

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Conflict of interest statement

Dr. Hyo-Soo Kim has received research grants or speaker's fees from Daiichi Sankyo, Boston Scientific, Terumo, Biotronik, Dio, Medtronic, Abbott Vascular, Edwards Life Science, Amgen, and Behringer Ingelheim, outside of the submitted work. Dr. Kyung Woo Park reports speaker's fees from Daiichi Sankyo, AstraZeneca, Sanofi, Bristol-Myers Squibb, Bayer, and Pfizer, outside of the submitted work. All other authors declare no competing interests.

Figures

Figure 1
Figure 1. Study flow chart.
NSTE-ACS = non-ST-segment elevation acute coronary syndrome; RP-ACS = REDUCE-POLYTECH-ACS; STEMI = ST-elevation myocardial infarction.
Figure 2
Figure 2. Primary endpoint in the intention-to-treat population at 1-year follow-up: (A) primary endpoint, (B) efficacy outcomes (cardiac death, myocardial infarction, stent thrombosis, and ischemic stroke), and (C) safety outcomes (BARC ≥2 bleeding events).
CI = confidence interval; HR = hazard ratio; NSTE-ACS = non-ST-segment elevation acute coronary syndrome; STEMI = ST-elevation myocardial infarction.
Figure 3
Figure 3. Prespecified landmark analysis at 4 weeks after index procedure: (A) primary endpoint, (B) efficacy outcomes (cardiac death, myocardial infarction, stent thrombosis, and ischemic stroke), and (C) safety outcomes (BARC ≥2 bleeding events).
CI = confidence interval; HR = hazard ratio; NSTE-ACS = non-ST-segment elevation acute coronary syndrome; STEMI = ST-elevation myocardial infarction. *Model fitted by penalized maximum likelihood.
See this image and copyright information in PMC

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