De-escalation from prasugrel to clopidogrel at the 12-month landmark after percutaneous coronary intervention with drug-eluting stents for acute myocardial infarction: a Korea Acute Myocardial Infarction Registry–National Institutes of Health cohort study

초록

Background – Guidelines recommend 12 months of potent P2Y12 inhibitor-based dual antiplatelet therapy after acute myocardial infarction–drug‐eluting stents (AMI–DES) percutaneous coronary intervention, but the optimal strategy beyond 1 year remains unclear. We evaluated the clinical impact of de-escalating from prasugrel to clopidogrel at the 12-month landmark. Methods – Using the nationwide Korea Acute Myocardial Infarction Registry–National Institutes of Health registry, we identified AMI patients who underwent successful percutaneous coronary intervention with DES and remained event free on aspirin–prasugrel (ASA/PSG) for 12 months. Patients were categorized into those who continued ASA/PSG or de-escalated to aspirin–clopidogrel (ASA/CPG). The primary endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, or stroke during months 12–24. Propensity score matching was used to adjust for confounders. Results – Among 967 eligible patients, 384 continued ASA/PSG and 304 de-escalated to ASA/CPG. In the unmatched cohort, the cumulative incidence of the primary endpoint was lower in the ASA/CPG group (log-rank P = 0.045). In the propensity score matching cohort (250 pairs), there were no significant differences between the ASA/CPG and ASA/PSG groups for the primary endpoint (P = 0.316) or the secondary composite (P = 0.378). Absolute event rates were notably low in both groups; specifically, no definite/probable stent thrombosis or major bleeding occurred during the second year. Propensity score-adjusted Cox models confirmed these neutral findings (hazard ratio: 1.06, 95% confidence interval: 0.52–2.12). Conclusion – In stabilized AMI–DES survivors, de-escalating to clopidogrel at 12 months showed no significant difference in observed clinical outcomes compared with continued prasugrel, alongside a favorable safety profile. These findings suggest that clopidogrel-based de-escalation may be a reasonable step-down strategy in the second year, aligning with personalized therapy recommendations. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.

키워드