Crushed Prasugrel Tablets Before Primary PCI Does Not Improve Outcomes in Patients With STEMI
By Eric Ramos
CHICAGO -- October 19, 2020 -- Prehospital administration of crushed tablets of prasugrel, compared with integral prasugrel tablets, in patients with ST-elevation myocardial infarction (STEMI) undergoing planned primary percutaneous coronary intervention (PCI) did not improve TIMI 3 flow in the infarct-related artery at first angiography, or ST-segment resolution at 1 hour post-PCI.
The findings were presented at TCT Connect, the 2020 Virtual Transcatheter Cardiovascular Therapeutics Meeting, by George J. Vlachojannis, MD, University Medical Center Utrecht, Utrecht, the Netherlands.
For the study, the researchers randomised patients with STEMI with symptom onset ≤6 hours planned for primary PCI to receive crushed or integral prasugrel 60 mg in the ambulance, in addition to aspirin and heparin. All patients were being transferred to 1 of 2 PCI centres in Rotterdam, the Netherlands. The intent-to-treat analysis included 333 patients randomised to receive crushed tablets and 300 patients randomised to receive integral tablets.
The primary endpoints were TIMI 3 flow in the infarct-related artery at first angiography and ≥70% ST-segment resolution 1 hour after primary PCI.
Results showed that crushed prasugrel tablets did not improve TIMI 3 flow compared with integral prasugrel tablets in the infarct-related artery (31% for crushed vs 32.7% integral; odds ratio [OR] = 0.92; 95% confidence interval [CI], 0.65-1.30). Similarly, crushed tablets did not improve complete ST-segment resolution 1 hour post-primary PCI (59.9% vs 57.3%; OR = 1.11; 95% CI, 0.78-1.58).
“These findings hold in spite of the fact that crushed tablets of prasugrel lead to more potent platelet inhibition compared with integral tablets,” said Dr. Vlachojannis.
A substantial and significant reduction was seen in the proportion of patients with platelet reactivity in the beginning of primary PCI in the crushed prasugrel group (62% vs 43%).
Clinical outcomes at 30 days, including all-cause mortality, myocardial reinfarction, coronary revascularisation, stroke, and bailout use of glycoprotein IIb/IIIa inhibitors, did not differ significantly between groups.
“Importantly, definitive and probable stent thrombosis rates were similar between groups,” said Dr. Vlachojannis.
A subgroup analysis found that the TIMI 3 endpoint did benefit patients aged ≥75 years, those with a history of previous PCI, and those with a presentation of anterior infarction.
The crushed prasugrel tablets were safe with no excess in bleeding.
“Whether faster and more potent antiplatelet therapy can improve coronary reperfusion in contemporary STEMI treatment regimen warrants further investigation,” said Dr. Vlachojannis.
[Presentation title: Effect of Pre-Hospital Crushed Prasugrel Tablets in Patients With STEMI Planned for Primary Percutaneous Coronary Intervention. The COMPARE CRUSH Trial. Late-Breaking Clinical Science Session I]