Can prasugrel decrease the extent of periprocedural myocardial injury during elective percutaneous coronary intervention?

INTRODUCTION Periprocedural myocardial injury may be associated with an increased risk of cardiovascular events. There is limited evidence on the safety and efficacy of more potent P2Y (12)antagonists in the reduction of the incidence of periprocedural myocardial injury among patients undergoing elective percutaneous coronary intervention (PCI) with inadequate response to clopidogrel. OBJECTIVES The aim of the study was to evaluate the impact of prasugrel on the incidence of periprocedural myocardial injury among patients undergoing elective PCI with inadequate response to clopidogrel, diagnosed by point-of-care genotyping and platelet function testing (PFT). PATIENTS AND METHODS This was a prespecified interim analysis of the randomized, open-label ONSIDE TEST study. Patients with stable coronary artery disease (CAD) scheduled for PCI were randomized to one of the following study arms: 1) genotyping, 2) PFT, or 3) control, and evaluated by the CYP2C19 allele genotyping and PFT with the P2Y(12)assay. Patients with poor response to clopidogrel by genotyping or PFT were loaded with 60 mg of prasugrel before PCI. The incidence of periprocedural myocardial injury was analyzed. RESULTS A total of 94 patients (genotyping, 34; PFT, 34; control, 26) were analyzed. Of the 25 patients (26.6%) with inadequate response to clopidogrel, 13 were switched to prasugrel while 12 continued dual antiplatelet therapy with clopidogrel. While similar rates of any periprocedural myocardial injury were found in the genotyping, PFG, and control arms (76.5%, 73.5%, and 73.1%, respectively), the incidence of periprocedural myocardial injury tended to be lower in the subset of patients with poor response to clopidogrel who were treated with prasugrel (61.5% vs 91.7%, P = 0.078). CONCLUSIONS Guided early prasugrel administration may decrease the extent of periprocedural myocardial injury during PCI in patients with stable CAD.