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

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Citation: Clinical Research in Cardiology. 109(6):725-734, 2020 Jun.PMID: 31915997Institution: MedStar Heart & Vascular InstituteForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Acute Coronary Syndrome/th [Therapy] | *Percutaneous Coronary Intervention | *Postoperative Complications/ep [Epidemiology] | *Prasugrel Hydrochloride/tu [Therapeutic Use] | *Preoperative Care/mt [Methods] | Acute Coronary Syndrome/di [Diagnosis] | Acute Coronary Syndrome/pp [Physiopathology] | Aged | Coronary Angiography | Electrocardiography | Female | Follow-Up Studies | Humans | Incidence | Male | Middle Aged | Platelet Aggregation Inhibitors/tu [Therapeutic Use] | Prospective Studies | Survival Rate/td [Trends] | Treatment Outcome | United States/ep [Epidemiology]Year: 2020ISSN:
  • 1861-0684
Name of journal: Clinical research in cardiology : official journal of the German Cardiac SocietyAbstract: BACKGROUND: Prasugrel is a potent thienopyridine that may be preferentially used in younger patients with lower bleeding risk.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.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.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.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).All authors: Aquino M, Baber U, Baker BA, Chandrasekhar J, Claessen BE, Dangas G, DeFranco A, Effron MB, Ge Z, Henry TD, Kapadia S, Keller S, Kini AS, Mehran R, Moalem K, Muhlestein JB, Pocock S, Rao SV, Sartori S, Strauss C, Toma C, Vogel B, Weintraub W, Weiss SOriginally published: Clinical Research in Cardiology. 2020 Jan 08Fiscal year: FY2020Digital Object Identifier: Date added to catalog: 2020-01-31
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Journal Article MedStar Authors Catalog Article 31915997 Available 31915997

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

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.

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.

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.

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).

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