Mortality Benefit With Prasugrel in the TRITON–TIMI 38 Coronary Artery Bypass Grafting Cohort

Abstract

Objectives The objective of this study is to characterize the bleeding, transfusion and other outcomes of patients related to the timing of prasugrel or clopidogrel withdrawal prior to coronary artery bypass grafting (CABG). Background There is little evidence to guide clinical decision making regarding the use of prasugrel in patients who may need urgent or emergency CABG. Experience with performing CABG in the presence of clopidogrel has raised concern about perioperative bleeding complications that are unresolved. Methods A subset of the TRITON TIMI 38 study, where patients with acute coronary syndrome were randomized to treatment with aspirin and either clopidogrel or prasugrel, underwent isolated CABG (N=346). A supplemental case report form was designed and administered, and the data combined with the existing TRITON-TIMI 38 database. Baseline imbalances were corrected for using elements of the European System for Cardiac Operative Risk Evaluation and The Society of Thoracic Surgeons predictive algorithm. Results A significantly higher mean 12 hr chest tube blood loss (655±580 ml vs. 503±378 ml, p=0.050) was observed with prasugrel compared to clopidogrel, without significant differences in red blood cell transfusion (2.1 units vs. 1.7 units, p=0.442) or the total donor exposure (4.4 units vs. 3.0 units, p=0.463). All-cause mortality was significantly reduced with prasugrel (2.31%) compared to 8.67% with clopidogrel (adjusted odds ratio [OR], 0.26, p=0.025). Conclusion Despite an increase in observed bleeding, platelet transfusion and surgical re-exploration for bleeding, prasugrel was associated with a lower rate of death following CABG compared to clopidogrel.

Outcome of CABG with or without Coronary Endarterectomy in Bangladesh: A Retrospective Cohort Study

“…Now-a-days off-pump CABG surgery for multi vessel myocardial revascularization in high risk patients has been appeared to decrease the frequency of perioperative morbidity and mortalityand the duration of hospital stay 7, 9 . In a study, Smith et al observed that majority of patients are belongs to 61 to 70-year age group, which is similar to our study 8 .Islamoglu et al shows that total myocardial revascularization improves LV function postoperatively 10 .The low occurrence of readmission to the intensive care unit (ICU), come back to theater for bleeding or cardiac tamponade, infection, and stroke in these highrisk patients in our OPCABG series with concurrent CE contrasts positively with published OPCABG articles 11 . Inadequate myocardial revascularization has been appeared to be a standout amongst the most critical components that influences perioperative outcome, ventricular function, early and late mortality 12, 13 .…”

Anti-thromboembolic strategies in atrial fibrillation

“…In the 2015 ESC guidelines [36], prasugrel and ticagrelor have class I recommendations for the treatment of ACS and there is a class II indication for the recently approved cangrelor. Based on the TRITON-TIMI 38 [60,61] and PLATO [62] trials, the guidelines recommend a 12-month DAPT with new DES. In selected cases the duration of DAPT could be longer than 12 months, for clopidogrel or prasugrel up to 30 months [60][61][62][63][64], for ticagrelor up to 48 months [61,62,65].…”

“…Based on the TRITON-TIMI 38 [60,61] and PLATO [62] trials, the guidelines recommend a 12-month DAPT with new DES. In selected cases the duration of DAPT could be longer than 12 months, for clopidogrel or prasugrel up to 30 months [60][61][62][63][64], for ticagrelor up to 48 months [61,62,65]. However, because of observed bleeding complications it is recommend not using prasugrel prior to PCI-SI [60][61][62][63][64].…”

“…The PEGASUS-TIMI 54 trial [cited in 36] suggests that the superior anti-thromboembolic efficacy of DAPT with aspirin + ticagrelor comes at cost of increased bleeding events. In the observational TRITON-TIMI 38 trial [60,61], prasugrel was compared with clopidogrel in DAPT: minor and major bleeding occurred significantly (p < 0.03) more often with prasugrel than with clopidogrel and no significant difference in ischemic endpoints was observed. Thus, we know that ticagrelor and prasugrel are more effective in ACS but cause more bleeding than clopidogrel.…”

Management of Antiplatelet Therapy in Patients With Coronary Artery Disease Requiring Cardiac and Noncardiac Surgery

“…This includes not only patients who have undergone stent implantation, but also those with an acute coronary syndrome (ACS) who are medically treated, in whom the clustering of adverse thrombotic events has been described in the early period after interruption of oral antiplatelet agents. [10][11][12] The risk of a recurrent ischemic event for patients discontinuing or not adhering to aspirin treatment has been suggested to increase 3-fold, with similar estimates of risk in patients with an ACS, on secondary prevention for CAD and those undergoing coronary artery bypass grafting (CABG), and higher risk in patients treated with DESs. 13 Importantly, stent thrombosis is a serious complication that is known to commonly present with death or a large nonfatal myocardial infarction, usually with ST elevation.…”