Thrombotic risk in patients with acute coronary syndromes discharged on prasugrel or clopidogrel: Results from the PROMETHEUS study

Mauro Chiarito, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
Davide Cao, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.Follow
Samantha Sartori, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
Zhongjie Zhang, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
Birgit Vogel, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
Alessandro Spirito, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
Kenneth F. Smith, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
William Weintraub, Christiana Care Health System, Newark, Delaware.
Craig Strauss, Division of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota.
Catalin Toma, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Anthony DeFranco, Advocate Aurora HealthFollow
Mark B. Effron, John Ochsner Heart and Vascular Institute, New Orleans, Lousiana.
Giulio Stefanini, Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy.
Stuart Keller, Eli Lilly and Company, Indianapolis, IN, USA.
Samir Kapadia, Cleveland Clinic, Cleveland, Ohio.
Sunil V. Rao, Division of Cardiology, NYU Langone Health System, NY, NY, USA.
Timothy D. Henry, The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH.
Stuart Pocock, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Samin Sharma, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
George Dangas, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.Follow
Annapoorna Kini, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
Usman Baber, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.Follow
Roxana Mehran, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.

Affiliations

Aurora Cardiovascular Services

Abstract

Background:Based on recent clinical data, the 2020 ESC guidelines on non-ST elevation acute coronary syndrome (NSTE-ACS) suggest to tailor antithrombotic strategy on individual thrombotic risk. Nonetheless, prevalence and prognostic impact of the high thrombotic risk (HTR) criteria proposed are yet to be described.

Methods and results: PROMETHEUS was a multicenter prospective study comparing prasugrel vs. clopidogrel in ACS patients undergoing PCI. In this analysis, we assessed prevalence and prognostic impact of HTR, defined according to the 2020 ESC NSTE-ACS guidelines, and if the benefits associated with prasugrel vs. clopidogrel vary with thrombotic risk. Patients were at HTR if presenting with one clinical plus one procedural risk feature. The primary endpoint was major adverse cardiac events (MACE), composite of death, myocardial infarction, stroke, or unplanned revascularization, at 1 year. Adjusted hazard ratio (adjHR) and 95% confidence intervals (CI) were calculated with propensity score stratification and multivariable Cox regression.Among 16065 patients, 4293 (26.7%) were at HTR and 11772 (73.3%) at low-to-moderate thrombotic risk. HTR conferred increased incidence of MACE (23.3 vs. 13.6%, HR 1.85, 95% CI 1.71 - 2.00, p < 0.001) and its single components. Prasugrel was prescribed in patients with less comorbidities and risk factors and was associated with reduced risk of MACE (HTR: adjHR 0.83, 95%CI 0.68-1.02; low-to-moderate risk: adjHR 0.75, 95%CI 0.64-0.88; pinteraction = 0.32).

Conclusion: High thrombotic risk, as defined by the 2020 ESC NSTE-ACS guidelines, is highly prevalent among ACS patients undergoing PCI. The high thrombotic risk definition had a strong prognostic impact, as it successfully identified patients at increased 1-year risk of ischemic events.

Type

Article

PubMed ID

37459570

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