• Prasugrel Leads P2Y12 Inhibitors for STEMI Still needed: consensus on bridging to oral agents

    Adverse outcomes after primary percutaneous coronary intervention (PCI) for patients

    with ST-segment elevation myocardial infarction (STEMI) are less frequent with

    prasugrel (Effient) than with other drugs in the P2Y  12  antagonist class, a meta-analysis


    At 1 month, the evidence tipped toward fewer major adverse cardiovascular events

    (MACE) with prasugrel than clopidogrel (standard dose odds ratio 0.59, 95% CI 0.50-

    0.69) or ticagrelor (standard dose OR 0.69, 95% CI 0.56-0.84), according to Timothy D.

    Henry, MD, of Cedars-Sinai Heart Institute in Los Angeles, and colleagues writing

    in JACC: Cardiovascular Interventions.

    Stroke rates were also lower with prasugrel versus clopidogrel (standard dose OR 0.36,

    95% CI 0.17-0.70) as were rates of stent thrombosis (standard dose OR 0.48, 95% CI


    Stroke, but not stent thrombosis, was also more likely with ticagrelor over prasugrel

    (standard dose OR 0.30, 95% CI 0.18-0.58).

    One year after PCI, prasugrel was the P2Y  12  inhibitor associated with the fewest deaths

    and MACE, the difference especially pronounced when patients also got bivalirudin and

    drug-eluting stents. What’s more, as was seen in earlier analyses, rates of bleeding were

    similar between P2Y 12  inhibitors.

    “Our study highlights the need for a randomized clinical trial to compare various

    P2Y 12  inhibitors in STEMI patients,” the investigators concluded. The meta-analysis

    included 37 studies with a total of 88,402 patients.

    Yet in an accompanying editorial, William Wijns, MD, PhD, of Belgium’s

    Cardiovascular Research Center Aalst, and colleagues suggested that the evidence

    currently in hand may be sufficient for choosing among the P2Y 12  antagonists.

    “It seems unlikely that a large enough dedicated comparative randomized trial will ever

    be performed, for two important reasons: funding of such a trial will be difficult, and,

    most important, today, identifying a winner among oral antiplatelet drugs with delayed

    onset of action, be it prasugrel or ticagrelor, is no longer a major, clinically relevant

    issue,” Wijns and colleagues wrote.

    Given the hours required for oral agents to take effect, they noted, “intravenous

    compounds may be even more effective in bridging patients to the full effect of oral

    antiplatelet agents.”

    Instead of comparing P2Y  12  inhibitors, the editorialists called for trials investigating a

    strategy of using both intravenous and oral agents.

    “In patients with acute thrombotic events, use of an antiplatelet agent with a fast onset of

    action, a predictable effect, and a fast offset is the best option, which will be provided by

    an intravenously administered drug,” Wijns and colleagues wrote. “During primary PCI

    for STEMI and the early in-hospital phase, the intravenous drug will cover the gap in

    platelet inhibition before the full effect of the oral drug.”

    “As to improving long-term prognosis, the intensity and duration of oral antiplatelet

    therapy will be tailored to each patient’s need, balancing ischemic and bleeding risks,”

    they suggested.


    Henry disclosed serving on steering committes for TRANSLATE (sponsored by Eli Lily

    and Daiichi-Sankyo) and Artemis (supported by AstraZeneca).

    Wijns reported receiving institutional grant funding from Medtronic, Boston Scientific,

    Terumo, MiCell, Microport, St. Jude Medical, Stentys, AstraZeneca, Biotronik, and

    Abbott Vascular; and serving as a non-executive board member and shareholder of

    Argonauts Partners, Celyad, and Genae.


    JACC: Cardiovascular Interventions


    Rafique AM, et al “Optimal P2Y 12  inhibitor in patients with ST-segment elevation

    myocardial infarction undergoing primary percutaneous coronary intervention: a network

    meta-analysis” JACC Cardiovasc Interv 2016; DOI: 10.1016/j.jcin.2016.02.013.

    JACC: Cardiovascular Interventions


    Cuisset T, et al “Optimal P2Y 12  inhibitor for primary percutaneous coronary intervention

    in ST-segment elevation myocardial infarction: network meta-analysis in the data-free

    zone: do you believe in magic?” JACC Cardiovasc Interv 2016; DOI:


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