Optimal Same-Day Platelet Inhibition in Patients Receiving Drug-Eluting Stents With or Without Previous Maintenance Thienopyridine Therapy: from the Evaluation of Platelet Inhibition in Patients Having A VerifyNow Assay (EPIPHANY) Trial.
We determined if high on-treatment platelet reactivity (HTPR) can be overcome on the day of percutaneous coronary intervention (PCI) in patients with or without previous maintenance thienopyridine therapy. Patients with HTPR, as defined as P2Y12 reaction units (PRU) >230, were switched to an alternate thienopyridine. Patients with HTPR undergoing PCI are at increased risk for ischemic complications. A total of 429 patients undergoing PCI with drug-eluting stents were enrolled. Patients on maintenance thienopyridine (n = 249) with PRU >230 were loaded with the alternative thienopyridine. Patients who were thienopyridine naïve (n = 180) were randomized to clopidogrel 600 (n = 90) or prasugrel 60 mg (n = 90). Patients with HTPR were loaded with the alternative agent. Patients on maintenance clopidogrel (n = 192) had a higher prevalence of HTPR compared with prasugrel (n = 57; 51% vs 4%, p <0.001). Patients on maintenance clopidogrel with HTPR (n = 98) who were loaded with prasugrel achieved PRU ≤230 in 97%. Thienopyridine-naïve patients loaded with clopidogrel had a higher prevalence of HTPR compared with prasugrel (37% vs 3%, p <0.001). Clopidogrel-loaded patients with HTPR (n = 33) who were reloaded with prasugrel achieved PRU ≤230 in 94%. All 3 prasugrel-loaded patients with HTPR treated with clopidogrel achieved PRU ≤230. Two patients experienced 30-day major adverse clinical events. One patient experienced Thrombolysis In Myocardial Infarction major bleeding. In conclusion, HTPR can be overcome in patients with and without previous maintenance thienopyridine therapy by identifying patients with HTPR and switching to an alternate thienopyridine.
Division of Cardiology, UCLA Medical Center, Los Angeles, California.
Michael S
MS
Lee
Department of Cardiology, Northwell Health, Manhasset, New York.
Evan
E
Shlofmitz
Cardiology Department, St. Francis Hospital-The Heart Center, Roslyn, New York.
Elizabeth
E
Haag
Cardiology Department, St. Francis Hospital-The Heart Center, Roslyn, New York.
Lyn
L
Santiago
Cardiology Department, St. Francis Hospital-The Heart Center, Roslyn, New York; Computer Information systems and Decision Sciences, St. John's University, Queens, New York.
Simcha
S
Pollack
Cardiology Department, St. Francis Hospital-The Heart Center, Roslyn, New York; Research Department, St. Francis Hospital-The Heart Center, Roslyn, New York; Cardiovascular Division, Department of Medicine, Stony Brook University School of Medicine, Stony Brook, New York; Department of Biomedical Engineering, Stony Brook University School of Medicine, Stony Brook, New York.
Nathaniel
N
Reichek
Cardiology Department, St. Francis Hospital-The Heart Center, Roslyn, New York. Electronic address: Richard.shlofmitz@chsli.org.
Richard A
RA
Shlofmitz
D000077144:Clopidogrel; D003327:Coronary Disease / Q000628:therapy*; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D010979:Platelet Function Tests; D000068799:Prasugrel Hydrochloride / Q000008:administration & dosage / Q000627:therapeutic use*; D011725:Pyridines / Q000008:administration & dosage / Q000627:therapeutic use*; D012307:Risk Factors; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000627:therapeutic use; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors; D011725:Pyridines; C446540:thienopyridine; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine