title: Infarct Size Following Treatment With Second- Versus Third-Generation P2Y12 Antagonists in Patients With Multivessel Coronary Disease at ST-Segment Elevation Myocardial Infarction in the CvLPRIT Study.
abstract: Third-generation P2Y12 antagonists (prasugrel and ticagrelor) are recommended in guidelines on ST-segment elevation myocardial infarction. Mechanisms translating their more potent antiplatelet activity into improved clinical outcomes versus the second-generation P2Y12 antagonist clopidogrel are unclear. The aim of this post hoc analysis of the Complete Versus Lesion-Only PRImary PCI Trial-CMR (CvLPRIT-CMR) substudy was to assess whether prasugrel and ticagrelor were associated with reduced infarct size compared with clopidogrel in patients undergoing primary percutaneous coronary intervention.
  
  
  
  CvLPRIT-CMR was a multicenter, prospective, randomized, open-label, blinded end point trial in 203 ST-segment elevation myocardial infarction patients with multivessel disease undergoing primary percutaneous coronary intervention with either infarct-related artery-only or complete revascularization. P2Y12 inhibitors were administered according to local guidelines. The primary end point of infarct size on cardiovascular magnetic resonance was not significantly different between the randomized groups. P2Y12 antagonist administration was not randomized. Patients receiving clopidogrel (n=70) compared with those treated with either prasugrel or ticagrelor (n=133) were older (67.8±12 versus 61.5±10 years, P<0.001), more frequently had hypertension (49% versus 29%, P=0.007), and tended to have longer symptom-to-revascularization time (234 versus 177 minutes, P=0.05). Infarct size (median 16.1% [quartiles 1-3, 10.5-27.7%] versus 12.1% [quartiles 1-3, 4.8-20.7%] of left ventricular mass, P=0.013) and microvascular obstruction incidence (65.7% versus 48.9%, P=0.022) were significantly greater in patients receiving clopidogrel. Infarct size remained significantly different after adjustment for important covariates using both generalized linear models (P=0.048) and propensity score matching (P=0.025).
  
  
  
  In this analysis of CvLPRIT-CMR, third-generation P2Y12 antagonists were associated with smaller infarct size and lower microvascular obstruction incidence versus the second-generation P2Y12 antagonist clopidogrel for ST-segment elevation myocardial infarction.
  
  
  
  URL: http://www.isrctn.com/ISRCTN70913605.
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, UK NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK jk211@le.ac.uk.
authors.forename: Jamal N
authors.initials: JN
authors.lastname: Khan
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK.
authors.forename: John P
authors.initials: JP
authors.lastname: Greenwood
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, UK NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK.
authors.forename: Sheraz A
authors.initials: SA
authors.lastname: Nazir
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, UK NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK.
authors.forename: Florence Y
authors.initials: FY
authors.lastname: Lai
authors.affiliation: Royal Brompton and Harefield Foundation Trust, Harefield Hospital, Middlesex, UK.
authors.forename: Miles
authors.initials: M
authors.lastname: Dalby
authors.affiliation: University Hospital Southampton NHS Foundation Trust and University of Southampton, UK.
authors.forename: Nick
authors.initials: N
authors.lastname: Curzen
authors.affiliation: Kettering General Hospital, Kettering, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Hetherington
authors.affiliation: Royal Derby Hospital, Derby, UK.
authors.forename: Damian J
authors.initials: DJ
authors.lastname: Kelly
authors.affiliation: Multidisciplinary Cardiovascular Research Centre & The Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK.
authors.forename: Daniel
authors.initials: D
authors.lastname: Blackman
authors.affiliation: University Hospital Southampton NHS Foundation Trust and University of Southampton, UK.
authors.forename: Charles
authors.initials: C
authors.lastname: Peebles
authors.affiliation: Royal Brompton and Harefield Foundation Trust, Harefield Hospital, Middlesex, UK.
authors.forename: Joyce
authors.initials: J
authors.lastname: Wong
authors.affiliation: Norfolk and Norwich University Hospitals NHS Foundation Trust and Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: Marcus
authors.initials: M
authors.lastname: Flather
authors.affiliation: The Heart Hospital, University College London Hospitals, London, UK.
authors.forename: Howard
authors.initials: H
authors.lastname: Swanton
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, UK NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK.
authors.forename: Anthony H
authors.initials: AH
authors.lastname: Gershlick
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, UK NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK.
authors.forename: Gerry P
authors.initials: GP
authors.lastname: McCann
mesh_terms: D000241:Adenosine / Q000008:administration & dosage / Q000031:analogs & derivatives; D000368:Aged; D000077144:Clopidogrel; D017023:Coronary Angiography; D023921:Coronary Stenosis / Q000188:drug therapy / Q000473:pathology; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D055806:Microvessels; D008875:Middle Aged; D009204:Myocardial Revascularization; D009929:Organ Size; D062645:Percutaneous Coronary Intervention; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage*; D000068799:Prasugrel Hydrochloride / Q000008:administration & dosage; D011446:Prospective Studies; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage*; D000072657:ST Elevation Myocardial Infarction / Q000188:drug therapy* / Q000473:pathology; D000077486:Ticagrelor; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine
keywords: antiplatelet therapy; cardiovascular magnetic resonance; infarct size; myocardial infarction; primary percutaneous coronary intervention