Crushed Prasugrel significantly Lowers Platelet Activity In Patients undergoing PCI: Study

ST-segment elevation myocardial infarction (STEMI) is the term cardiologists use to describe a classic heart attack. It is one type of myocardial infarction in which a part of the heart muscle (myocardium) has died due to the obstruction of blood supply to the area. As a treatment strategy, STEMI patients are directly taken to the cardiac catheterization laboratory to undergo mechanical revascularization. This is called Primary Percutaneous Coronary Intervention. Anti-platelet therapy is given to such patients. However, the onset of action varies according to the formulation administered.

With this background, Dr. Ashish Kumar Aggarwal carried out a study to compare the pharmacodynamic effects of prasugrel in crushed versus integral tablet formulation in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).

The trial randomized 441 patients with suspected STEMI and they were given crushed or integral prasugrel 60-mg loading dose in the ambulance. Pharmacodynamic measurements were performed at 4 time points: before antiplatelet treatment, at the beginning and end of pPCI, and 4 h after study treatment onset. The primary endpoint was high platelet reactivity at the end of pPCI. The secondary endpoint was impact of platelet reactivity status on markers of coronary reperfusion.

The study showed some interesting results:

In patients with crushed prasugrel, the occurrence of high platelet reactivity at the end of pPCI was reduced by almost one-half (crushed 34.7% vs. uncrushed 61.6%; odds ratio [OR] = 0.33; 95% confidence interval [CI] = 0.22 to 0.50; p < 0.01).

Platelet reactivity <150 P2Y12 reactivity units at the beginning of coronary angiography correlated with improved Thrombolysis In Myocardial Infarction flow grade 3 in the infarct artery pre-pPCI (OR: 1.78; 95% CI: 1.08 to 2.94; p = 0.02) but not ST-segment resolution (OR: 0.80; 95% CI: 0.48 to 1.34; p = 0.40).

The results of this study demonstrate that pre-hospital administration of crushed prasugrel significantly lowers platelet reactivity before and after pPCI in patients presenting with STEMI.

"However, a considerable number of patients still exhibit inadequate platelet inhibition at the end of pPCI, suggesting the need for alternative agents to bridge the gap in platelet inhibition," the investigators concluded.

Reference:

Study titled, "Pharmacodynamic Effects of Pre-Hospital Administered Crushed Prasugrel in Patients With ST-Segment Elevation Myocardial Infarction," published in the Journal of the American College of Cardiology.

DOI: https://doi.org/10.1016/j.jcin.2021.04.022