Author + information
- Iñigo Lozano, MD, PhD∗ (, )
- Juan Rondan, MD, PhD and
- Jose M. Vegas, MD
- ↵∗Cardiología, Hospital de Cabueñes, Avda, Los Prados 385, Gijón, Asturias 33203, Spain
We read with great interest the paper by Montalescot et al. (1) and the editorial by Ibanez and Dangas (2) about prasugrel in non–ST-segment myocardial infarction (NSTEMI), and we appreciate the research on this interesting issue. The ACCOAST (A Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST Elevation Myocardial Infarction) trial demonstrated that pre-treatment with prasugrel in NSTEMI adds no benefit compared with initiating the drug after angiography and also was associated with an increase in bleeding events (3). In the same way, in the subgroup of patients analyzed in the ACCOAST-PCI, the results are concordant with the main study in terms of same clinical outcome as well as a higher rate of bleeding events (1).
As is pointed out in the editorial, both the recent American College of Cardiology/American Heart Association and the European Society of Cardiology guidelines recommend prasugrel in NSTEMI only after angiography, and this fact places prasugrel as a second-line agent. Although prasugrel showed benefit over clopidogrel in the TRITON (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel), the design of the trial was criticized due to the 300-mg loading dose of clopidogrel and also the administration after angiography instead of earlier, probably limiting the effect of clopidogrel, the effect of which takes longer to act.
In our opinion, the right comparison between prasugrel and clopidogrel in NSTEMI has still not been carried out. If we review both the results of the CREDO (Clopidogrel Maintaining Dosage in Acute Coronary Syndrome After Drug Eluting Stent Implantation) and ACCOAST, we can assume that the best moment to initiate clopidogrel would be as soon as possible after admission and just after the initial angiography for prasugrel. Both drugs have theoretical advantages such as an unrestricted spectrum of patients (4,5), fewer bleeding events, more experience with the drug, and lower cost of clopidogrel versus more rapid onset and action, a reduction in nonfatal coronary events and stent thrombosis, and avoiding the administration of the drug in patients who would need surgery once the anatomy is known for prasugrel. Although it is highly improbable that a prospective and adequately powered study will be designed 8 years after the publication of the TRITON trial and with the presence of ticagrelor in the market, we believe that the only way to have the correct answer for prasugrel and clopidogrel in NSTEMI would be to compare in ischemic and bleeding events the pre-treatment with clopidogrel with the administration of prasugrel after the initial angiography, and it would probably be the only way for prasugrel to once again become a first-line treatment for these patients.
Please note: Dr. Lozano has received honoraria for lectures about ticagrelor. The other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Montalescot G.,
- Collet J.P.,
- Ecollan P.,
- et al.,
- for the ACCOAST Investigators
- Ibanez B.,
- Dangas G.
- Hira R.S.,
- Kennedy K.,
- Jneid H.,
- et al.
- Lozano I, Gomez-Jaume A, De la Torre J, Perez-Serradilla A, Fernandez J, Fernandez-Portales J. Limitation to the utilization of the new antiplatelet agents in acute coronary syndromes related with patient’s characteristics. Rev Esp Cardiol (in press).