Safety and efficacy of different P2Y12 inhibitors in patients with acute coronary syndromes stratified by the PRAISE risk score: a multicentre study.

Abstract

AIMS:

To establish the safety and efficacy of different dual antiplatelet therapy (DAPT) combinations in patients with acute coronary syndrome (ACS) according to their baseline ischaemic and bleeding risk estimated with a machine learning derived model [machine learning-based prediction of adverse events following an acute coronary syndrome (PRAISE) score].

METHODS AND RESULTS:

Incidences of death, re-acute myocardial infarction (re-AMI), and Bleeding Academic Research Consortium 3-5 bleeding with aspirin plus different P2Y12 inhibitors (clopidogrel or potent P2Y12 inhibitors: ticagrelor or prasugrel) were appraised among patients of the PRAISE data set grouped in four subcohorts: low-to-moderate ischaemic and bleeding risk; low-to-moderate ischaemic risk and high bleeding risk; high ischaemic risk and low-to-moderate bleeding risk; and high ischaemic and bleeding risk. Hazard ratios (HRs) for the outcome measures were derived with inverse probability of treatment weighting adjustment. Among patients with low-to-moderate bleeding risk, clopidogrel was associated with higher rates of re-AMI in those at low-to-moderate ischaemic risk [HR 1.69, 95% confidence interval (CI) 1.16-2.51; P = 0.006] and increased risk of death (HR 3.2, 1.45-4.21; P = 0.003) and re-AMI (HR 2.23, 1.45-3.41; P < 0.001) in those at high ischaemic risk compared with prasugrel or ticagrelor, without a difference in the risk of major bleeding. Among patients with high bleeding risk, clopidogrel showed comparable risk of death, re-AMI, and major bleeding vs. potent P2Y12 inhibitors, regardless of the baseline ischaemic risk.

CONCLUSION:

Among ACS patients with non-high risk of bleeding, the use of potent P2Y12 inhibitors is associated with a lower risk of death and recurrent ischaemic events, without bleeding excess. Patients deemed at high bleeding risk may instead be safely addressed to a less intensive DAPT strategy with clopidogrel.

• Authors: Giuseppe Patti, Fabrizio D'Ascenzo, Ovidio De Filippo, Francesco Bruno, Sergio Leonardi, Alaide Chieffo, Mario Iannaccone, Christoph Liebetrau, Sergio Manzano-Fernández, Guglielmo Gallone, Pierluigi Omedè, Enrico Cerrato, Tim Kinnaird, Federico Conrotto, Francesco Piroli, Jose Paulo Simao Henriques, Wojciech Wańha, Edoardo Elia, Alberto Dominguez-Rodriguez, Sergio Raposeiras-Roubin, Emad Abu-Assi, Gaetano Maria De Ferrari, PRAISE Study Group
• Journal: European heart journal. Quality of care & clinical outcomes (Eur Heart J Qual Care Clin Outcomes) Vol. 8 Issue 8 Pg. 881-891 (11 17 2022) ISSN: 2058-1742 [Electronic] England
• PMID: 35022719 (Publication Type: Multicenter Study, Journal Article)
• Copyright: © The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.

Chemical References

• Ticagrelor
• Clopidogrel
• Prasugrel Hydrochloride
• Purinergic P2Y Receptor Antagonists
• Platelet Aggregation Inhibitors

Topics

• Humans
• Acute Coronary Syndrome (drug therapy)
• Ticagrelor (therapeutic use)
• Clopidogrel (therapeutic use)
• Prasugrel Hydrochloride (adverse effects)
• Purinergic P2Y Receptor Antagonists (adverse effects)
• Platelet Aggregation Inhibitors (adverse effects)
• Treatment Outcome
• Myocardial Infarction (epidemiology)
• Hemorrhage (chemically induced, epidemiology)
• Risk Factors