Clinical Research
Interventional Cardiology
Triple Therapy With Aspirin, Prasugrel, and Vitamin K Antagonists in Patients With Drug-Eluting Stent Implantation and an Indication for Oral Anticoagulation

https://doi.org/10.1016/j.jacc.2013.02.036Get rights and content
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Objectives

This study sought to evaluate whether prasugrel may serve as an alternative to clopidogrel in patients with triple therapy.

Background

Approximately 10% of patients who receive dual antiplatelet therapy after percutaneous coronary intervention have an indication for oral anticoagulation and are thus treated with triple therapy. The standard adenosine diphosphate receptor blocker in this setting is clopidogrel. Data regarding prasugrel as part of triple therapy are not available.

Methods

We analyzed a consecutive series of 377 patients who underwent drug-eluting stent implantation and had an indication for oral anticoagulation between February 2009 and December 2011 and were treated with a 6-month regimen of aspirin and oral anticoagulation with either prasugrel or clopidogrel. The primary endpoint was a composite of Thrombolysis In Myocardial Infarction (TIMI) major and minor bleeding at 6 months. The secondary endpoint was a composite of death, myocardial infarction, ischemic stroke, or definite stent thrombosis.

Results

Twenty-one patients (5.6%) received prasugrel instead of clopidogrel. These patients had a higher-risk profile at baseline, and the majority had high platelet reactivity to clopidogrel. TIMI major and minor bleeding occurred significantly more often in the prasugrel compared with the clopidogrel group (6 [28.6%) vs. 24 [6.7%]; unadjusted hazard ratio (HR): 4.6, 95% confidence interval [CI]: 1.9 to 11.4], p < 0.001; adjusted HR: 3.2, 95% CI: 1.1 to 9.1], p = 0.03). There was no significant difference regarding the combined ischemic secondary endpoint (2 [9.5%] vs. 25 [7.0%]; unadjusted HR: 1.4, 95% CI: 0.3 to 6.1], p = 0.61).

Conclusions

These findings suggest that substitution of prasugrel for clopidogrel in patients needing triple therapy increases the risk of bleeding. However, specific randomized trials are needed to define the role of newer adenosine diphosphate receptor antagonists in this setting.

Key Words

aspirin
clopidogrel
drug-eluting stent(s)
high platelet reactivity
prasugrel
vitamin K antagonist

Abbreviations and Acronyms

ADP
adenosine diphosphate
AU
arbitrary units
CI
confidence interval
DES
drug-eluting stent(s)
HPR
high platelet reactivity
HR
hazard ratio
INR
international normalized ratio
MACCE
major adverse cardiac and cerebrovascular ischemic event(s)
OAC
oral anticoagulation
PCI
percutaneous coronary intervention
TIMI
Thrombolysis In Myocardial Infarction

Cited by (0)

Dr. Sibbing is a consultant for Verum Diagnostica; and receives payment for lectures from Eli Lilly and Daiichi Sankyo. Dr. Mehilli has received lecture fees from Lilly/Daiichi Sankyo, AstraZeneca, Abbott Vascular, and Terumo. Dr. Kastrati has received payment for lectures from AstraZeneca, Daiichi Sankyo, and Eli Lilly. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.