Mortality benefit with prasugrel in the TRITON-TIMI 38 coronary artery bypass grafting cohort: risk-adjusted retrospective data analysis.
OBJECTIVE
The objective of this study was to characterize the bleeding, transfusion, and other outcomes of patients related to the timing of prasugrel or clopidogrel withdrawal before coronary artery bypass grafting (CABG).


BACKGROUND
There is little evidence to guide clinical decision making regarding the use of prasugrel in patients who may need urgent or emergency CABG. Experience with performing CABG in the presence of clopidogrel has raised concern about perioperative bleeding complications that are unresolved.


METHODS
A subset of the TRITON-TIMI 38 study (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis In Myocardial Infarction 38), in which patients with acute coronary syndrome were randomized to treatment with aspirin and either clopidogrel or prasugrel, underwent isolated CABG (N = 346). A supplemental case report form was designed and administered, and the data combined with the existing TRITON-TIMI 38 database. Baseline imbalances were corrected for using elements of the European System for Cardiac Operative Risk Evaluation and The Society of Thoracic Surgeons predictive algorithm.


RESULTS
A significantly higher mean 12-h chest tube blood loss (655 ± 580 ml vs. 503 ± 378 ml; p = 0.050) was observed with prasugrel compared with clopidogrel, without significant differences in red blood cell transfusion (2.1 U vs. 1.7 U; p = 0.442) or the total donor exposure (4.4 U vs. 3.0 U; p = 0.463). All-cause mortality was significantly reduced with prasugrel (2.31%) compared with 8.67% with clopidogrel (adjusted odds ratio: 0.26; p = 0.025).


CONCLUSIONS
Despite an increase in observed bleeding, platelet transfusion, and surgical re-exploration for bleeding, prasugrel was associated with a lower rate of death after CABG compared with clopidogrel.
Duke University Medical Center, Durham, NC 27710, USA. smith058@mc.duke.edu
Peter K
PK
Smith
Lawrence T
LT
Goodnough
Jerrold H
JH
Levy
Robert S
RS
Poston
Mary A
MA
Short
Govinda J
GJ
Weerakkody
Leroy A
LA
Lenarz
D054058:Acute Coronary Syndrome / Q000401:mortality / Q000601:surgery*; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000401:mortality; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D016063:Blood Loss, Surgical; D002423:Cause of Death; D015505:Chest Tubes; D000077144:Clopidogrel; D015331:Cohort Studies; D003131:Combined Modality Therapy; D001026:Coronary Artery Bypass / Q000401:mortality*; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D017707:Erythrocyte Transfusion; D005260:Female; D005500:Follow-Up Studies; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D010879:Piperazines / Q000008:administration & dosage* / Q000009:adverse effects*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects*; D000068799:Prasugrel Hydrochloride; D012008:Recurrence; D012189:Retrospective Studies; D020379:Risk Adjustment; D013876:Thiophenes / Q000008:administration & dosage* / Q000009:adverse effects*; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*
D010879:Piperazines; D010975:Platelet Aggregation Inhibitors; D013876:Thiophenes; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine; D001241:Aspirin