Comparison of Platelet Function Guided Versus Unguided Treatment With P2Y12 Inhibitors in Patients With Acute Myocardial Infarction (from the Hungarian Myocardial Infarction Registry)

Abstract

Evidence is conflicting regarding the clinical benefits of selecting P2Y inhibitors based on platelet function testing (PFT). Between March 1, 2013 and March 1, 2014, we collected clinical characteristics and platelet function data in a nationwide acute myocardial infarction (AMI) registry from 15 interventional cardiology centers in Hungary. The risk of all-cause mortality at 1 year were compared after propensity score (PS) matching between patients receiving PFT-guided and unguided P2Y-inhibitor therapies. High platelet reactivity on clopidogrel (HPRoC) was uniformly defined with the Multiplate assay. A total of 5,583 patients with AMI and coronary intervention were registered. After exclusion of cases with contraindication to prasugrel, propensity matching resulted in a sample of 2,104 patients with well-adjusted characteristics. Clopidogrel was the dominant P2Y inhibitor in both groups (unguided: 96% vs PFT guided: 85%, p <0.001). In the PFT-guided group, 19% of patients had HPRoC and 77% of them were switched to prasugrel. According to the adjusted analysis, all-cause mortality at 1 year was significantly lower in the PFT-guided compared with the unguided group (hazard ratio 0.57 [95% confidence interval 0.43 to 0.77], p <0.001). Although prasugrel treatment was not associated with lower all-cause mortality in the overall cohort, patients with HPRoC who switched to prasugrel had significantly lower mortality when compared with those continuing clopidogrel (hazard ratio 0.33 [95% confidence interval 0.12 to 0.92], p <0.05). In conclusion, in patients with AMI, PFT-guided treatment with a high rate of switchover to prasugrel was associated with a lower risk of mortality. Prasugrel was a predictor of lower mortality in patients with HPRoC but not in the overall cohort of AMI.

Platelet function testing guided antiplatelet therapy reduces cardiovascular events in Chinese patients with ST‐segment elevation myocardial infarction undergoing percutaneous coronary intervention: The PATROL study

“…For HPR patients, a personalized antiplatelet treatment with selective intensification of P2Y12 receptor inhibition has been investigated in several previous studies . In the ISAR‐HPR registry, retreatment with clopidogrel, switch to prasugrel, and reassessment of platelet function were associated with a significant decrease in the incidence of adverse events when compared to historical controls .…”

“…34 For HPR patients, a personalized antiplatelet treatment with selective intensification of P2Y12 receptor inhibition has been investigated in several previous studies. 7,8,35,36 In the ISAR-HPR registry, retreatment with clopidogrel, switch to prasugrel, and reassessment of platelet function were associated with a significant decrease in the incidence of adverse events when compared to historical controls. 36 The CREATIVE randomized study indicated that the intensified antiplatelet strategy with adjunctive use of cilostazol significantly improved clinical outcomes of patients with low response to clopidogrel.…”

“…In recent years, several studies have focused on platelet function testing (PFT)‐guided antiplatelet therapy . However, PFT‐ or genotype‐guided antiplatelet therapy is not recommended by current guidelines, given the uncertainty of this precision medical approach in improving clinical outcomes .…”

“…In recent years, several studies have focused on platelet function testing (PFT)-guided antiplatelet therapy. [7][8][9][10][11][12] However, PFT-or genotype-guided antiplatelet therapy is not recommended by current guidelines, given the uncertainty of this precision medical approach in improving clinical outcomes. [13][14][15][16] Compared to genotyping, the PFT is more cost-effective in determining responses to antiplatelet therapy.…”

Use of drug‐eluting stents in elderly patients with acute myocardial infarction

“…The Hungarian Myocardial Infarction Registry (HUMIR) is a prospective, registry collecting clinical data on consecutive patients treated for an AMI in Hungary. The data on capture and follow‐up procedures of the HUMIR has already been published in details previously 4‐7 . Briefly, the patient's data are collected prospectively according to the statute of CCXLVI./2013 of Hungary via a national internet‐based registry.…”