The European Society of Cardiology recently announced the 2020 ESC guidelines for the management of non-ST-elevation acute coronary syndrome (NSTE-ACS), recommending prasugrel rather than ticagrelor as a P2Y-12 inhibitor to treat patients who underwent percutaneous coronary intervention (PCI). With the latest recommendation by ESC, physicians are likely to use prasugrel more.

A group of local researchers said they have come up with a new treatment strategy, reduced-dose prasugrel, that significantly lowered the bleeding risk of ACS patients who underwent PCI. The new method maintained the effect of preventing recurrence of ischemic events, they said.

The primary outcome of the HOST-REDUCE-POCYTECH-ACS trial, presented by Kim Hyo-soo, a professor at the Cardiology Department of Seoul National University Hospital, at the ESC Congress 2020 on Aug. 31.

During the online ESC Congress 2020 on Aug. 31, Professor Kim Hyo-soo of the Cardiology Department at Seoul National University Hospital presented his investigator-initiated study at the late-breaking science session.

Kim said physicians have used a combination of aspirin and a P2Y-12 inhibitor as the standard therapy in ACS patients with a high risk of thrombosis. However, the ISAR-REACT5 trial released in the New England Journal of Medicine in 2019 chose prasugrel over ticagrelor among P2Y-12 inhibitors, he said.

In the HOST-REDUCE-POLYTECH-ACS study, the researchers divided patients who received PCI, suitable for prasugrel therapy, into two groups. One received a gradual reduction of prasugrel and the other, the conventional prasugrel, for 12 months.

The researchers set the primary endpoint as net adverse clinical events (NACE) that included stent thrombosis and bleeding at one year.

The results showed that only 7.2 percent of the patients treated with the reduced-dose prasugrel had NACE, while 10.1 percent of the other group with the conventional prasugrel did so. From day 30 where different doses of prasugrel were given, the former group had a 34 percent lower chance of NACE, compared to the latter.

Kim also said the secondary outcomes analyzing thrombosis and bleeding events separately. The incidence of thrombotic events, including heart death, myocardial infarction, stent thrombus, and ischemic stroke, was 1.4 percent in the de-escalation prasugrel group, and 1.8 percent in the conventional treatment group. The difference between the two was not statistically meaningful.

On the other hand, the incidence of bleeding higher than Bleeding Academic Research Consortium (BARC) 2 was 2.9 percent in the reduced-dose group, versus 5.9 percent in the standard treatment group. It shows that the reduced-dose of prasugrel lowered the bleeding risk markedly, by about 52 percent. Such results were consistent in sub-group analysis on patients, Kim said.

Reduced-dose prasugrel significantly lowered the risk of NACE occurrence, compared to the conventional standard therapy,” Kim said. “The results of the study demonstrated that reduced-dose prasugrel can be a positive treatment strategy that balances the ischemic and bleeding risks in ACS patients that underwent PCI.”

kym@docdocdoc.co.kr

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