Impact of prasugrel pretreatment and timing of coronary artery bypass grafting on clinical outcomes of patients with non-ST-segment elevation myocardial infarction: From the A Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST-Elevation Myocardial Infarction (ACCOAST) study.

Abstract

OBJECTIVES:

We evaluated impact of timing of coronary artery bypass grafting (CABG) and prasugrel pretreatment in patients with non-ST-segment elevation myocardial infarction undergoing CABG in the ACCOAST study.

METHODS:

Of 4033 enrolled patients, 314 (7.8%) underwent isolated CABG through 30 days. Primary efficacy end point for this analysis was any cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa inhibitor bailout through 30 days.

RESULTS:

More CABG versus percutaneous coronary intervention or medically managed patients were men, diabetic, or had peripheral arterial disease. Per randomization, 157 of 314 patients received a 30-mg prasugrel loading dose before CABG, and 157 of 314 received placebo. Patients were stratified by tertile of time from randomization to CABG: <2.98 days (n = 104), ≥2.98 and <6.95 days (n = 106), and ≥6.95 days (n = 104). Primary end point occurred in 12.5%, 4.7%, and 4.8%, respectively (<2.98 days vs other tertiles, hazard ratio [HR] = 2.80; P = .011). Similarly, the rate of all TIMI major bleeding was highest in the lowest tertile (26.0% vs 10.4% and 4.8%; P < .001), but no difference in all-cause death was observed through 30 days (3.9% vs 1.9% and 1.9%; P = .30). Time from randomization to CABG (HR = 0.84 for each day delay), left main disease (HR = 1.76), region of enrollment (Non-Eastern Europe vs Eastern Europe; HR = 3.83), but not prasugrel pretreatment and baseline troponin ≥3× upper limit of normal, were independent predictors of combined 30-day end point of all-cause death/myocardial infarction/stroke/TIMI major bleeding.

CONCLUSIONS:

In ACCOAST, early (<2.98 days) surgical revascularization carried increased risk of bleeding and ischemic complications without affecting all-cause mortality through 30 days. Baseline troponin and prasugrel pretreatment did not impact ischemic clinical outcomes.

• Authors: Dariusz Dudek, Artur Dziewierz, Petr Widimsky, Leonardo Bolognese, Patrick Goldstein, Christian Hamm, Jean-Francois Tanguay, LeRoy LeNarz, Debra L Miller, Eileen Brown, Jurrien Ten Berg, Gilles Montalescot, ACCOAST Investigators
• Journal: American heart journal (Am Heart J) Vol. 170 Issue 5 Pg. 1025-1032.e2 (Nov 2015) ISSN: 1097-6744 [Electronic] United States
• PMID: 26542513 (Publication Type: Clinical Trial, Phase III, Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2015 Elsevier Inc. All rights reserved.

Chemical References

• Prasugrel Hydrochloride

Topics

• Aged
• Coronary Artery Bypass (methods)
• Dose-Response Relationship, Drug
• Electrocardiography
• Female
• Humans
• Male
• Middle Aged
• Myocardial Infarction (diagnosis, therapy)
• Percutaneous Coronary Intervention (methods)
• Prasugrel Hydrochloride (administration & dosage)
• Preoperative Care (methods)
• Treatment Outcome