Pretreatment with Prasugrel in Non–ST-Segment Elevation Acute Coronary Syndromes

Abstract

Among patients with NSTE acute coronary syndromes who were scheduled to undergo catheterization, pretreatment with prasugrel did not reduce the rate of major ischemic events up to 30 days but increased the rate of major bleeding complications. (Funded by Daiichi Sankyo and Eli Lilly; ACCOAST ClinicalTrials.gov number, NCT01015287.).

2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

“…Było to jedyne RCT, w którym oceniano wczesne podanie inhibitora P2Y 12 w NSTE-ACS [164]. W badaniu ACCOAST porównano wczesne nasycenie pacjentów prasugrelem w dawce 30 mg i kolejne 30 mg przed PCI z podawaniem 60 mg prasugrelu po diagnostycznej koronarografii, lecz przed PCI.…”

Antithrombotic therapy for acute coronary syndrome: Past, present and future

“…A separate topic, which is discussed in detail elsewhere (64,65), is the issue of pretreatment with the potent P2Y 12 receptor inhibitors in NSTEMI (66) and STEMI patients (67). Based upon the results of the ACCOAST) trial (66), showing a higher risk of bleeding but not improvement in efficacy for pre-treatment, it is not recommended to administer prasugrel in NSTEMI patients in whom the coronary anatomy is not known (Class III, LOE B).…”

“…Based upon the results of the ACCOAST) trial (66), showing a higher risk of bleeding but not improvement in efficacy for pre-treatment, it is not recommended to administer prasugrel in NSTEMI patients in whom the coronary anatomy is not known (Class III, LOE B). This may also apply to ticagrelor for pretreatment in NSTEMI patients but this specific drug was not investigated in that scenario.…”

Precatheterization Use of P2Y 12 Inhibitors in Non‐ST‐Elevation Myocardial Infarction Patients Undergoing Early Cardiac Catheterization and In‐Hospital Coronary Artery Bypass Grafting: Insights From the National Cardiovascular Data Registry ®

“…This concept was later challenged when the CREDO (Clopidogrel for the Reduction of Events During Observation) trial showed no benefit from pretreatment with clopidogrel given 3 hours before PCI but suggested potential reduction of events in patients with longer duration from clopidogrel administration to catheterization 10. The ACCOAST (A Comparison of Prasugrel at PCI or Time of Diagnosis of Non‐ST Elevation Myocardial Infarction) trial showed that precatheterization use of prasugrel did not improve cardiovascular outcomes and was associated with an increase in TIMI (Thrombosis in Myocardial Infarction) major bleeding 6. There are no data comparing precatheterization use and nonuse of ticagrelor in NSTEMI.…”

“…Nevertheless, data from this time period5 showed that only 57% of NSTEMI patients received P2Y 12 inhibitors within the first 24 hours of admission. The benefits of precatheterization P2Y 12 inhibitor use with faster‐onset, higher‐potency agents such as prasugrel and ticagrelor are less certain, with some studies suggesting lack of benefit and higher bleeding risk with early treatment 6. In 2014, the American College of Cardiology/American Heart Association guidelines changed their recommendation to “before stenting” instead of “as soon as possible.” This change reflected, in part, a trend toward much earlier coronary angiography in current practice7 as well as concerns for revascularization delays in patients who are subsequently discovered to need coronary artery bypass grafting (CABG).…”