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.
Résumé
Contexte
Les puissants inhibiteurs de P2Y12 peuvent procurer des bienfaits accrus contre les accidents thrombotiques dans le
cadre d’une intervention coronarienne percutanée (ICP) complexe. Nous avons étudié
l’utilisation du prasugrel et les résultats en fonction de la complexité de l'ICP,
de même que nous avons analysé les effets du traitement selon le type de thiénopyridine.
Méthodologie
PROMETHEUS était une étude observationnelle multicentrique visant à comparer le clopidogrel
au prasugrel chez des patients atteints d’un syndrome coronarien aigu qui ont subi
une ICP (n = 19 914). L'ICP complexe était définie comme une ICP à l’artère coronaire
gauche, une lésion de bifurcation, une lésion calcifiée modérée ou grave ou l’installation
d’une endoprothèse d’une longueur totale d’au moins 30 mm. Les événements cardiaques
indésirables majeurs (ECIM) comprenaient les décès, les infarctus du myocarde, les
accidents vasculaires cérébraux ou les revascularisations non prévues. Les résultats
ont été corrigés au moyen du modèle de régression de Cox à plusieurs variables pour
tenir compte de l’effet de la complexité de l'ICP ainsi que d’une analyse stratifiée
selon la propension pour tenir compte de l’effet du type de thiénopyridine.
Résultats
La cohorte de l’étude comprenait 48,9 % (n = 9735) de cas complexes et 51,1 % (n =
10 179) de cas non complexes. Des endoprothèses médicamentées de deuxième génération
ont été utilisées chez 70,1 % des patients subissant une ICP complexe et chez 66,2
% des patients subissant une ICP non complexe (p < 0,0001). L'ICP complexe a été associée à un risque corrigé accru d'ECIM après un
an (rapport de risques instantanés [RRI], 1,29; intervalle de confiance [IC] à 95
%, 1,20 à 1,39; p < 0,001). Le prasugrel a été prescrit à 20,7 % des patients ayant subi une ICP complexe
et à 20,1 % des patients ayant subi une ICP non complexe (p = 0,30). Comparativement au clopidogrel, le prasugrel a considérablement réduit le
risque corrigé d'ECIM après un an dans les cas d'ICP complexes (RRI, 0,79; IC à 95
%, 0,68 à 0,92), mais pas dans les cas d'ICP non complexes (RR, 0,91; IC à 95 %, 0,77
à 1,08), bien qu’il n’y ait eu aucun signe d’interaction (p interaction = 0,281).
Conclusions
Malgré l’utilisation de techniques contemporaines, les patients atteints d’un syndrome
coronarien aigu qui subissent une ICP ont affiché un taux considérablement accru d'ECIM
après un an. L’ampleur corrigée des effets thérapeutiques du prasugrel par rapport
au clopidogrel a été comparable dans les ICP et non complexes, sans signe d’interaction.
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Article info
Publication history
Published online: December 27, 2017
Accepted:
December 19,
2017
Received:
November 28,
2017
Footnotes
See page 327 for disclosure information.
Identification
Copyright
© 2018 Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society.
