ACCOAST-PCI Evaluates Pretreatment Strategy With Prasugrel

December 19, 2014—Gilles Montalescot, MD, et al published findings from the ACCOAST-PCI study in the Journal of the American College of Cardiology (JACC; 2014;64:2563–2571). ACCOAST is a comparison of administering prasugrel at the time of percutaneous coronary intervention (PCI) versus administering it as pretreatment at the time of diagnosis in patients with non–ST-segment elevation myocardial infarction (NSTEMI).

The investigators concluded that the ACCOAST findings support deferring treatment with prasugrel until a decision is made about revascularization in patients with NSTEMI undergoing angiography within 48 hours of admission.

The background of the study is that treatment with a P2Y12 antagonist with aspirin is recommended for 1 year after PCI for NSTEMI. Although the oral P2Y12 antagonists (prasugrel or ticagrelor) have higher recommendations than clopidogrel, it is unknown if administration before the start of PCI is beneficial.

As summarized in JACC, ACCOAST is a randomized, double-blind trial. In the study, 4,033 patients were diagnosed with NSTEMI, and 68.7% underwent PCI; of these PCI patients, 1,394 received pretreatment with prasugrel (30-mg loading dose), and 1,376 received placebo. At the time of PCI, patients who received pretreatment with prasugrel received an additional 30-mg dose of prasugrel, and those who received placebo received a 60-mg loading dose of prasugrel. Primary efficacy was a composite of cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa bailout through 7 days from randomization. Investigators captured the presence of thrombus on initial angiography and during PCI.

The ACCOAST investigators found that the incidence of the primary endpoint through 7 days from randomization in the pretreatment group versus the no-pretreatment group was 13.1% versus 13.1% (P = .93). Pretreatment with prasugrel was not associated with decreases in any ischemic event, including total mortality. Patients with thrombus on angiography had a threefold higher incidence of the primary endpoint than patients without thrombus. There was no impact of pretreatment with prasugrel on the presence of thrombus before PCI or on occurrence of stent thrombosis after PCI.

Additionally, there was a threefold increase in all noncoronary artery bypass graft thrombolysis in myocardial infarction (TIMI) major bleeding and a sixfold increase in non–coronary artery bypass graft life-threatening bleeding with pretreatment with prasugrel; the same trends persisted in patients who had radial or femoral access even with use of a closure device, reported the investigators in JACC.