Prasugrel De-Escalation Therapy After Complex Percutaneous Coronary Intervention in Acute Coronary Syndrome: A Subgroup Analysis of the HOST-REDUCE-POLYTECH-ACS Randomized Clinical Trial

Abstract

Background De-escalation of dual-antiplatelet therapy through dose reduction of prasugrel improved net adverse clinical events (NACE) after acute coronary syndrome (ACS), mainly through the reduction of bleeding without an increase in ischemic outcomes. We sought to investigate whether such benefits are maintained in the complex percutaneous coronary intervention (PCI) subgroup.

Methods This is a post hoc analysis of the HOST-REDUCE-POLYTECH-ACS trial. In the prasugrel randomization arm of the main trial, patients were randomized to prasugrel de-escalation (5 mg daily) or conventional (10 mg daily) groups at 1 month post-PCI. Complex was defined as having at least 1 of the following features: 3 vessels treated, ≥ 3 stents implanted, ≥3 lesions treated, bifurcation PCI, total stent length > 60 mm, left main PCI, or heavy calcification. The primary outcome was NACE (a composite of all-cause death, nonfatal myocardial infarction, stent thrombosis, repeat revascularization, stroke, and BARC [Bleeding Academic Research Consortium] class ≥ 2 bleeding events) at 1 year.

Results Of 2,271 patients for whom full procedural data were available, 705 patients received complex PCI, and 1,566 patients received noncomplex PCI. Complex PCI was associated with higher rates of ischemic outcomes but not with bleeding outcomes. In the complex PCI group, prasugrel de-escalation significantly reduced the risk of NACE at 1 year (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.37-0.95; P = 0.031). Prasugrel de-escalation did not increase the risk of ischemic outcomes (cardiovascular death, nonfatal myocardial infarction, stent thrombosis, and repeat revascularization) (HR: 0.88; 95% CI: 0.47-1.66; P = 0.695) but significantly decreased BARC class ≥ 2 bleeding (HR: 0.25; 95% CI: 0.10-0.61; P = 0.002).

Conclusion In patients with ACS receiving complex PCI, prasugrel-based de-escalation compared with conventional therapy significantly reduced the risk of bleeding without increasing the risk of ischemia.

Categories CORONARY: Pharmacology and Pharmacotherapy