Abstract 9309: Benefit of Prasugrel in ST-Elevation Myocardial Infarction According to Timing of Percutaneous Coronary Intervention: Insight from the TRITON-TIMI 38 Study
Background: Prasugrel is approved as an alternative to clopidogrel in STEMI. Treatment strategies and outcomes for primary PCI (<12 hours from onset [PPCI]) versus secondary PCI (>12 hours from onset or initial medical therapy [SecPCI]) may differ.
Methods: We performed a pre-specified analysis within the 3534 STEMI patients in TRITON-TIMI 38. Patients were randomized to prasugrel or clopidogrel on presentation if PPCI was intended or at the time of SecPCI. Since the clinical importance of procedural MI remains controversial, we performed sensitivity analyses excluding these events from the primary endpoint.
Results: 2340 (68%) STEMI patients underwent PPCI. As previously reported, the reduction in the primary endpoint (CV death, MI, or stroke) with prasugrel versus clopidogrel was significant in STEMI patients at 30 days (30d) and 15 months (15m). Efficacy appeared consistent among PPCI patients (30d HR 0.81 [95% CI 0.60-1.09]; 15m HR 0.89 [0.69-1.13]) and SecPCI patients (30d HR 0.51 [0.34-0.76]; 15m HR 0.65 [0.46-0.93]; Figure 1+2). There was no interaction between timing of PCI and randomized treatment with respect to outcome at 30d or 15m (p-interaction>0.05 for both). Reduction in CV death/spontaneous MI/stroke with prasugrel remained consistent among PPCI and SecPCI patients (Figure 1+2) with no interaction with timing of PCI and treatment (p-interaction>0.05 for both). Trends in reduction of spontaneous MI were observed in PPCI (30d HR 0.53 [0.28-1.01]; 15m HR 0.72 [0.48-1.10]) and SecPCI (30d HR 0.26 [0.09-0.80] and 15m HR 0.57 [0.29-1.14]). TIMI major bleeding events were infrequent, however bleeding associated with prasugrel as compared to clopidogrel was consistent in the STEMI cohort, and either PCI subgroup, with the overall trial result (PPCI 15m HR 1.52 [0.87-2.65]; SecPCI 15m HR 0.39 [0.14-1.11]).
Conclusion: In patients with STEMI, the efficacy and safety of prasugrel as compared to clopidogrel is consistent irrespective of the timing of PCI.
- © 2011 by American Heart Association, Inc.