ACCOAST: A Comparison of Prasugrel at the Time of Percutaneous Coronary Intervention or as Pre-treatment At the Time of Diagnosis in Patients with Non-ST-Elevation Myocardial Infarction.

Presented at the ESC congress 2013 by: Gilles MONTALESCOT (Paris, FR)

Background

The ACCOAST (A Comparison of prasugrel at PCI or Time of Diagnosis of Non-ST Elevation Myocardial Infarction) trial studied the potential benefits and risks of pretreatment with the P2Y12 antagonist prasugrel at non-ST-elevation myocardial infarction (NSTEMI) patients with elevated troponin who have to undergo a coronary angiography or percutaneous coronary intervention (PCI).
The difference between pretreatment with prasugrel or only treatment at the time of PCI were specifically investigated in patients with acute coronary syndrome.

Main results

• After 30 days there was no difference in the primary endpoint of CV mortality, MI and stroke, between pretreatment with prasugrel and prasugrel treatment only at the time of PCI (HR: 0.997, 95%CI: 0.83-1.20, P=0.98).

• Major bleeding occurred almost twice as often after pretreatment, after 7 days as well as after 30 days (HR: 1.97, 95%CI: 1.26-3.08, P=0.002).
• Subanalysis of patients who indeed underwent PCI gave similar results with regard to the efficacy, and a slightly higher risk of bleedings (HR: 2.65, 95%CI: 1.23-5.70, P=0.010).
• No subgroup of patients was identified for whom pretreatment with prasugrel gave a favourable risk/effect-ratio.

Conclusion

In NSTE-ACS patients who are treated invasively within 48 hours after hospital admission, pretreatment with prasugrel does not lower the risk of major ischaemic events until 30 days after treatment. It does increase the number of major bleedings. There seems to be no subgroup of patients for whom prasugrel pretreatment is beneficial. Re-appraisal of routine pretreatment with prasugrel is therefore needed.

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