Impact of an integrated treatment algorithm based on platelet function testing and clinical risk assessment: results of the TRIAGE Patients Undergoing Percutaneous Coronary Interventions To Improve Clinical Outcomes Through Optimal Platelet Inhibition study.
Assessment of platelet reactivity alone for thienopyridine selection with percutaneous coronary intervention (PCI) has not been associated with improved outcomes. In TRIAGE, a prospective multicenter observational pilot study we sought to evaluate the benefit of an integrated algorithm combining clinical risk and platelet function testing to select type of thienopyridine in patients undergoing PCI. Patients on chronic clopidogrel therapy underwent platelet function testing prior to PCI using the VerifyNow assay to determine high on treatment platelet reactivity (HTPR, ≥230 P2Y12 reactivity units or PRU). Based on both PRU and clinical (ischemic and bleeding) risks, patients were switched to prasugrel or continued on clopidogrel per the study algorithm. The primary endpoints were (i) 1-year major adverse cardiovascular events (MACE) composite of death, non-fatal myocardial infarction, or definite or probable stent thrombosis; and (ii) major bleeding, Bleeding Academic Research Consortium type 2, 3 or 5. Out of 318 clopidogrel treated patients with a mean age of 65.9 ± 9.8 years, HTPR was noted in 33.3 %. Ninety (28.0 %) patients overall were switched to prasugrel and 228 (72.0 %) continued clopidogrel. The prasugrel group had fewer smokers and more patients with heart failure. At 1-year MACE occurred in 4.4 % of majority HTPR patients on prasugrel versus 3.5 % of primarily non-HTPR patients on clopidogrel (p = 0.7). Major bleeding (5.6 vs 7.9 %, p = 0.47) was numerically higher with clopidogrel compared with prasugrel. Use of the study clinical risk algorithm for choice and intensity of thienopyridine prescription following PCI resulted in similar ischemic outcomes in HTPR patients receiving prasugrel and primarily non-HTPR patients on clopidogrel without an untoward increase in bleeding with prasugrel. However, the study was prematurely terminated and these findings are therefore hypothesis generating.
Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY, USA.
Jaya
J
Chandrasekhar
Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY, USA.
Usman
U
Baber
Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY, USA.
Roxana
R
Mehran
Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY, USA.
Melissa
M
Aquino
Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY, USA.
Samantha
S
Sartori
Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY, USA.
Jennifer
J
Yu
Mount Sinai Hospital, New York, NY, USA.
Annapoorna
A
Kini
Mount Sinai Hospital, New York, NY, USA.
Samin
S
Sharma
Charité University Hospital, Berlin, Germany.
Carsten
C
Skurk
St. Francis Hospital, New York, NY, USA.
Richard A
RA
Shlofmitz
HELIOS Amper-Klinikum Dachau, Dachau, Germany.
Bernhard
B
Witzenbichler
Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY, USA. george.dangas@mountsinai.org.|Mount Sinai Hospital, New York, NY, USA. george.dangas@mountsinai.org.
George
G
Dangas
D000368:Aged; D000465:Algorithms; D000066491:Clinical Decision-Making / Q000379:methods*; D000077144:Clopidogrel; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D010979:Platelet Function Tests / Q000706:statistics & numerical data; D000068799:Prasugrel Hydrochloride / Q000627:therapeutic use; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods; D058924:Thienopyridines / Q000627:therapeutic use*; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors; D058924:Thienopyridines; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine
High on treatment platelet reactivity; Platelet function testing; Potent P2Y12 receptor inhibitor; Thienopyridine switching; VerifyNow assay