High-On Treatment Platelet Reactivity as a Risk Factor for Secondary Prevention after Coronary Stent Revascularization: A Landmark Analysis of the ARCTIC Study
Background—Individualizing antiplatelet therapy after platelet function testing did not improve outcome after coronary stenting in the ARCTIC study. Whether results are different during the phase of secondary prevention starting after hospital discharge, when peri-procedural events have been excluded, is unknown.
Methods and Results—In ARCTIC, 2,440 patients were randomized before coronary stenting to a strategy of platelet function monitoring (VerifyNowTM P2Y12/Aspirin point of care assay) with drug adjustment in suboptimal responders to antiplatelet therapy or to a conventional strategy without monitoring and without drug and/or dose changes. We performed a landmark analysis starting at the time of hospital discharge evaluating the primary end point of death, myocardial infarction, stent thrombosis, stroke or urgent revascularization through one year. After discharge, the primary end point occurred in 8.6% of patients in the monitoring arm and 7.9% in the conventional arm (HR 1.105; 95% CI [0.835;1.461], p=0.48). Stent thrombosis or urgent revascularization occurred in 4.4% and 4.5% in the monitoring and conventional arms, respectively (p=0.99). There was no difference for any of the other ischemic end points. Major bleeding event rates were 1.8% in the monitoring arm versus 2.8% in the conventional arm (p=0.11) while major or minor bleeding event rates were 2.3% and 3.4%, respectively (p=0.10).
Conclusions—Detection of platelet hyper-reactivity by platelet function testing in patients undergoing coronary stenting with further therapeutic adjustment does not reduce ischemic recurrences after intervention. On-treatment platelet hyper-reactivity cannot be considered as a risk factor requiring intervention for secondary prevention after percutaneous coronary revascularization.
Clinical Trial Registration Information—http://clinicaltrials.gov; Identifier: NCT00827411.
- Received November 21, 2013.
- Revision received February 13, 2014.
- Accepted March 3, 2014.