title: Upstream clopidogrel, prasugrel, or ticagrelor for patients treated with primary angioplasty: Results of an angiographic randomized pilot study.
abstract: OBJECTIVE
  The main objective of the present randomized pilot study was to explore the effects of upstream prasugrel or ticagrelor or clopidogrel for patients with ST-segment-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).
  
  
  BACKGROUND
  Administration of clopidogrel "as soon as possible" has been advocated for STEMI. Pretreatment with prasugrel and ticagrelor may improve reperfusion. Currently, the angiographic effects of upstream administration of these agents are poorly understood.
  
  
  METHODS
  A total of 132 patients with STEMI within the first 12 hr of chest pain referred to primary angioplasty were randomized to upstream clopidogrel (600 mg), prasugrel (60 mg), or ticagrelor (180 mg) while still in the emergency room. All patients underwent protocol-mandated thrombus aspiration.
  
  
  RESULTS
  Macroscopic thrombus material was retrieved in 79.5% of the clopidogrel group, 65.9% of the prasugrel group, and 54.3% of the ticagrelor group (P = 0.041). At baseline angiography, large thrombus burden was 97.7% vs. 87.8% vs. 80.4% in the clopidogrel, prasugrel, and ticagrelor groups, respectively (P = 0.036). Also, at baseline, 97.7% presented with an occluded target vessel in the clopidogrel group, 87.8% in the prasugrel group and 78.3% in the ticagrelor group (P = 0.019). At the end of the procedure, the percentages of patients with combined TIMI grade III flow and myocardial blush grade III were 52.3% for clopidogrel, 80.5% for prasugrel, and 67.4% for ticagrelor (P = 0.022).
  
  
  CONCLUSIONS
  In patients with STEMI undergoing primary PCI within 12 hr, upstream clopidogrel, prasugrel or ticagrelor have varying angiographic findings, with a trend toward better results for the latter two agents. © 2015 Wiley Periodicals, Inc.
authors.affiliation: Catheterization Laboratory, Hospital De Messejana, Dr. Carlos Alberto Studart Gomes, Fortaleza-CE, Brazil.|Department of Cardiology, Federal University of Ceara, Fortaleza-CE, Brazil.
authors.forename: José R
authors.initials: JR
authors.lastname: Mont'Alverne-Filho
authors.affiliation: Department of Cardiology, Federal University of Ceara, Fortaleza-CE, Brazil.
authors.forename: Carlos R M
authors.initials: CR
authors.lastname: Rodrigues-Sobrinho
authors.affiliation: Catheterization Laboratory, Hospital De Messejana, Dr. Carlos Alberto Studart Gomes, Fortaleza-CE, Brazil.|Department of Cardiology, Federal University of Ceara, Fortaleza-CE, Brazil.
authors.forename: Fernando
authors.initials: F
authors.lastname: Medeiros
authors.affiliation: Department of Cardiology, Federal University of Ceara, Fortaleza-CE, Brazil.
authors.forename: Francisco C
authors.initials: FC
authors.lastname: Falcão
authors.affiliation: Catheterization Laboratory, Hospital De Messejana, Dr. Carlos Alberto Studart Gomes, Fortaleza-CE, Brazil.|Department of Cardiology, Federal University of Ceara, Fortaleza-CE, Brazil.
authors.forename: Joao L
authors.initials: JL
authors.lastname: Falcão
authors.affiliation: Department of Interventional Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo-SP, Brazil.
authors.forename: Rafael C
authors.initials: RC
authors.lastname: Silva
authors.affiliation: Brigham and Women's Hospital, Harvard Medical School, Cardiovascular Division, Boston, Massachusetts.
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Croce
authors.affiliation: Department of Interventional Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo-SP, Brazil.
authors.forename: Jose C
authors.initials: JC
authors.lastname: Nicolau
authors.affiliation: Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, The Netherlands.
authors.forename: Marco
authors.initials: M
authors.lastname: Valgimigli
authors.affiliation: Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, The Netherlands.|International Centre for Circulatory Health, NHLI, Imperial College London, London, United Kingdom.
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
authors.affiliation: Department of Interventional Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo-SP, Brazil.
authors.forename: Pedro A
authors.initials: PA
authors.lastname: Lemos
mesh_terms: D000241:Adenosine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects; D001938:Brazil; D000077144:Clopidogrel; D017023:Coronary Angiography; D004334:Drug Administration Schedule; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D000068799:Prasugrel Hydrochloride / Q000008:administration & dosage* / Q000009:adverse effects; D011237:Predictive Value of Tests; D011446:Prospective Studies; D000072657:ST Elevation Myocardial Infarction / Q000000981:diagnostic imaging / Q000628:therapy*; D017131:Thrombectomy; D000077486:Ticagrelor; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine
keywords: acute myocardial infarction; antiplatelet therapy; coronary angiography; myocardial perfusion