Author + information
- J.H. Cornel,
- E. Magnus Ohman,
- Benjamin Neely,
- Peter Clemmensen,
- Piyamitr Sritara,
- Dmitry Zamoryakhin,
- Paul Armstrong,
- Dorairaj Prabhakaran,
- Harvey White,
- Keith Fox,
- Paul Gurbel and
- Matthew Roe
Active smoking is associated with increased thrombosis risk and enhanced efficacy of clopidogrel therapy vs placebo. Prasugrel metabolism is not influenced by smoking and has superior pharmacodynamic efficacy, but its relationship to clinical outcomes has not been evaluated in medically managed ACS.
7180 patients <75 y in TRILOGY ACS (prasugrel vs clopidogrel in medically managed ACS) were stratified as active smokers vs ex/nonsmokers. Event rates by smoking status were evaluated through 30 mos and relationships among smoking and treatment groups and clinical outcomes were assessed.
1566 (22%) were active smokers vs 5614 (78%) ex/nonsmokers at randomization. The former were younger, less commonly female and diabetic, and more likely to have prior MI, higher creatinine clearance, and prerandomization angiography (Table). At 30 mos, event rates for the composite of CVD/MI/stroke in active smokers were 11.7% (prasugrel) vs 20.8% (clopidogrel) with significant interaction between treatment and active smoking status for the composite and CVD and MI components. There was no difference in bleeding rates. Significant treatment interactions persisted for the composite endpoint (p=0.01) and CVD (p=0.01) after adjusting for baseline differences.
There is significant interaction with stronger platelet inhibition with prasugrel vs clopidogrel by smoking status in medically managed ACS patients and a significantly enhanced treatment effect with prasugrel.
|Baseline characteristics||Not active smoker (n=5614)||Active smoker (n=1566)||P|
|Median age, years (IQR)||63.0 (58.0, 69.0)||59.0 (52.0, 64.0)||<0.001|
|Female sex, %||40.3||20.4||<0.001|
|Diabetes mellitus, %||40.4||32.8||<0.001|
|Prior MI, %||42.9||47.8||<0.001|
|Median creatinine clearance, mL/min (IQR)||78.3 (60.4, 99.8)||90.0 (70.2, 114.0)||<0.001|
|Angiography performed, %||39.2||53.6||<0.001|
|Outcomes by treatment||Unadjusted hazard ratio (95% CI): prasugrel vs. clopidogrel||Unadjusted hazard ratio (95% CI): prasugrel vs. clopidogrel||Interaction P|
|CV death/MI/stroke||1.06 (0.90–1.25)||0.54 (0.39–0.74)||0.0002|
|CV death||1.12 (0.88–1.43)||0.48 (0.30–0.77)||0.0018|
|MI||0.98 (0.80–1.21)||0.62 (0.42–0.91)||0.0403|
Moderated Poster Contributions
Poster Sessions, Expo North
Sunday, March 10, 2013, 3:45 p.m.-4:30 p.m.
Session Title: ACS Therapy
Abstract Category: 3. Acute Coronary Syndromes: Therapy
Presentation Number: 1255M-176
- 2013 American College of Cardiology Foundation