Author + information
- Gilles Montalescot, MD, PhD∗ ()
- ↵∗Institut de Cardiologie, Pitié-Salpêtriėre University Hospital, 47, Boulevard de l’Hôpital, 75013 Paris, France
We thank Dr. Lozano and colleagues for their interest in our paper. However, they misinterpret the results of the ACCOAST (Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST Elevation Myocardial Infarction) and of the preceding trials. Placing the new P2Y12 antagonists in general and prasugrel in particular as a second-line treatment in non–ST-segment elevation myocardial infarction (NSTEMI) does not reflect the superiority demonstrated by these new drugs over clopidogrel in 2 pivotal trials. It does not comply with the current guidelines, especially for the patients undergoing percutaneous coronary intervention, as both prasugrel and ticagrelor have a class I recommendation, whereas clopidogrel should be given “only when prasugrel or ticagrelor are not available or are contraindicated” (1). So the first error is to believe that clopidogrel is still the gold standard for the treatment of NSTEMI.
The second error is to believe that pre-treatment with a P2Y12 antagonist is of benefit to NSTEMI patients. Pre-treatment is a treatment given to the patients while they wait to undergo coronary angiography. Although Dr. Lozano thinks that this is the right thing to do with clopidogrel, it has never been validated by a randomized study. This question of clopidogrel pre-treatment was not evaluated in the CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) study because the majority of patients did not have coronary angiography performed in this study. It was also not addressed by the CREDO (Clopidogrel for the Reduction of Events During Observation) study because the coronary status of the majority of patients was known at the time of randomization (2). No study evaluated pre-treatment with ticagrelor. So the only randomized trial to evaluate pre-treatment is the ACCOAST study, which showed harm and no benefit to the patients with pre-treatment.
Finally, despite the caveats of the CURE and CREDO trials, which favor pretreatment without really testing the hypothesis, when pooling the data from ACCOAST, CURE, and CREDO trials (N > 18,000), there was no decrease in mortality or ischemic events, but a significant 45% excess of major bleeding with thienopyridine pre-treatment (3). Both clopidogrel and pre-treatment are strategies of the past (4). However, we encourage Dr. Lozano to perform the study that he suggests in his conclusion.
Please note: Dr. Montalescot has reported receiving consulting fees from Bayer, Boehringer-Ingelheim, CFR, Europa, GLG, Iroko Cardio International, Lead-Up, LLC, Luminex, McKinsey, Remedica, Servier, TIMI Group, WebMD, and Wolters; consulting fees and grant support from Bristol-Myers Squibb, AstraZeneca, Biotronik, Eli Lilly, The Medicines Company, Medtronic, Menarini, Sanofi, Pfizer, and Accumetrics; and grant support from Abbott Vascular, Daiichi-Sankyo, Nanospheres, and Stentys.
- American College of Cardiology Foundation
- Windecker S.,
- Kolh P.,
- Alfonso F.,
- et al.
- Collet J.P.,
- Silvain J.,
- Bellemain-Appaix A.,
- Montalescot G.