Prasugrel use and clinical outcomes by age among patients undergoing PCI for acute coronary syndrome: from the PROMETHEUS study

Authors

Jaya ChandrasekharFollow
Usman BaberFollow
Samantha Sartori
Melissa Aquino
Kamilia Moalem
Annapoorna S Kini
Sunil V Rao
William Weintraub
Timothy D Henry
Birgit Vogel
Zhen Ge
Joseph B Muhlestein
Sandra Weiss
Craig Strauss
Catalin Toma
Anthony C. DeFranco, Advocate Aurora HealthFollow
Bimmer E ClaessenFollow
Stuart Keller
Brian A BakerFollow
Mark B Effron
Stuart Pocock
George DangasFollow
Samir Kapadia
Roxana Mehran

Recommended Citation

Chandrasekhar J, Baber U, Sartori S, et al. Prasugrel use and clinical outcomes by age among patients undergoing PCI for acute coronary syndrome: from the PROMETHEUS study. Clin Res Cardiol. 2020;109(6):725-734. doi: 10.1007/s00392-019-01561.

Affiliations

Aurora Cardiovascular Services

Abstract

BACKGROUND: Prasugrel is a potent thienopyridine that may be preferentially used in younger patients with lower bleeding risk.

OBJECTIVE: We compared prasugrel use and outcomes by age from the PROMETHEUS study. We also assessed age-related trends in treatment effects with prasugrel versus clopidogrel.

METHODS: PROMETHEUS was a multicenter acute coronary syndrome (ACS) percutaneous coronary intervention (PCI) registry. We compared patients in age tertiles (T1 < 60 years, T2 60-70 years, T3 > 70 years). Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke or unplanned revascularization. Data were adjusted using multivariable Cox regression for age-related risks and propensity score stratification for thienopyridine effects.

RESULTS: The study included 19,914 patients: 7045 (35.0%) in T1, 6489 (33.0%) in T2 and 6380 (32.0%) in T3. Prasugrel use decreased from T1 to T3 (29.2% vs. 23.5% vs. 7.5%, p < 0.001). Crude 1-year MACE rates were highest in T3 (17.4% vs. 16.8% vs. 22.7%, p < 0.001), but adjusted risk was similar between the groups (p-trend 0.52). Conversely, crude incidence (2.8% vs. 3.8% vs. 6.9%, p < 0.001) and adjusted bleeding risk were highest in T3 (HR 1.24, 95% CI 0.99-1.55 in T2; HR 1.83, 95% CI 1.46-2.30 in T3; p-trend < 0.001; reference = T1). Treatment effects with prasugrel versus clopidogrel did not demonstrate age-related trends for MACE (p-trend = 0.91) or bleeding (p-trend = 0.28).

CONCLUSIONS: Age is a strong determinant of clinical risk as well as prasugrel prescription in ACS PCI with much lower use among older patients. Prasugrel did not have a differential treatment effect by age for MACE or bleeding. Frequency of prasugrel use and age-related temporal risks of all-cause death and bleeding after ACS PCI.

Document Type

Article

PubMed ID

31915997