In a nutshell: The hottest developments in the field of cardiology in 2020. Section 5. Coronary artery disease

5. ALPHEUS (Ticagrelor versus clopidogrel in elective percutaneous coronary intervention) trial

Ticagrelor instead of clopidogrel fared no better with respect to protection from periprocedural myocardial infarction or major myocardial injury.

Patients with stable coronary artery disease were eligible for the study if they had an indication for PCI and at least one high-risk characteristic. Eligible patients were randomly assigned (1:1) to either ticagrelor (180 mg loading dose, 90 mg twice daily thereafter for 30 days) or clopidogrel (300–600 mg loading dose, 75 mg daily thereafter for 30 days).

Ticagrelor was not superior to clopidogrel in reducing periprocedural myocardial necrosis after elective PCI and did not cause an increase in major bleeding, but did increase the rate of minor bleeding at 30 days. These results support the use of clopidogrel as the standard of care for elective PCI.

Dipti Itchhaporia, MD (Hoag Memorial Hospital Presbyterian, Newport Beach, CA), said the trial should make interventional cardiologists think, particularly since many have grown more comfortable over the years using ticagrelor and prasugrel for patients with ACS and even in stable CAD patients with high-risk, complex anatomy. In one review, almost one-third of patients without ACS undergoing PCI between 2009 to 2016 were treated with prasugrel or ticagrelor, she said.

For that reason, “ALPHEUS is a really important data. I think the data does really make you pause and ask if [more potent antiplatelet therapy] is really necessary because it is more expensive, although prasugrel is generic so that’s not as big an issue, but if you’re using ticagrelor, [cost] is an issue”, she concluded.

Source: Lancet. Silvain J, Lattuca B, Beygui F, et al. Ticagrelor versus clopidogrel in elective percutaneous coronary intervention (ALPHEUS): a randomized, open-label, phase 3b trial. Lancet 2020 https://doi.org/10.1016/S0140-6736(20)32236-4

6. COMPARE CRUSH (COMPARison of pre-hospital CRUSHed vs. uncrushed Prasugrel tablets in patients with STEMI undergoing primary percutaneous coronary intervention) trial

Crushed prasugrel did not improve TIMI 3 flow at first angiography or complete ST-segment resolution at 1 hour post-PCI compared with integral prasugrel.

Eligible patients were randomized in a 1:1 fashion to either crushed (n = 369) or integral (n = 358) tablets of 60 mg prasugrel in the ambulance. They also received aspirin and heparin.

Crushed prasugrel did not improve TIMI 3 flow at first angiography or complete ST-segment resolution at 1 hour post-PCI compared with integral prasugrel, both of which were administered as a 60 mg load in the ambulance prior to PPCI among patients with suspected STEMI.

Source: Circulation journal: Vlachojannis G, Wilschut JM, Vogel R, et al. Effect of pre-hospital crushed prasugrel tablets in patients with STEMI planned for primary percutaneous coronary intervention: the randomized COMPARE CRUSH trial. Circulation 2020;Oct 14 https://doi.org/10.1161/CIRCULATIONAHA.120.051532