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Prasugrel use and clinical outcomes by age among patients undergoing PCI for acute coronary syndrome: from the PROMETHEUS study

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Abstract

Background

Prasugrel is a potent thienopyridine that may be preferentially used in younger patients with lower bleeding risk.

Objective

We compared prasugrel use and outcomes by age from the PROMETHEUS study. We also assessed age-related trends in treatment effects with prasugrel versus clopidogrel.

Methods

PROMETHEUS was a multicenter acute coronary syndrome (ACS) percutaneous coronary intervention (PCI) registry. We compared patients in age tertiles (T1 < 60 years, T2 60–70 years, T3 > 70 years). Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke or unplanned revascularization. Data were adjusted using multivariable Cox regression for age-related risks and propensity score stratification for thienopyridine effects.

Results

The study included 19,914 patients: 7045 (35.0%) in T1, 6489 (33.0%) in T2 and 6380 (32.0%) in T3. Prasugrel use decreased from T1 to T3 (29.2% vs. 23.5% vs. 7.5%, p < 0.001). Crude 1-year MACE rates were highest in T3 (17.4% vs. 16.8% vs. 22.7%, p < 0.001), but adjusted risk was similar between the groups (p-trend 0.52). Conversely, crude incidence (2.8% vs. 3.8% vs. 6.9%, p < 0.001) and adjusted bleeding risk were highest in T3 (HR 1.24, 95% CI 0.99–1.55 in T2; HR 1.83, 95% CI 1.46–2.30 in T3; p-trend < 0.001; reference = T1). Treatment effects with prasugrel versus clopidogrel did not demonstrate age-related trends for MACE (p-trend = 0.91) or bleeding (p-trend = 0.28).

Conclusions

Age is a strong determinant of clinical risk as well as prasugrel prescription in ACS PCI with much lower use among older patients. Prasugrel did not have a differential treatment effect by age for MACE or bleeding.

Graphic abstract

Frequency of prasugrel use and age-related temporal risks of all-cause death and bleeding after ACS PCI.

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Funding

The PROMETHEUS study was sponsored and funded by Daiichi Sankyo, Inc. and Eli Lilly and Company.

Author information

Authors and Affiliations

  1. Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA

    Jaya Chandrasekhar, Usman Baber, Samantha Sartori, Melissa Aquino, Kamilia Moalem, Birgit Vogel, Zhen Ge, Bimmer E. Claessen, George Dangas & Roxana Mehran

  2. Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands

    Jaya Chandrasekhar

  3. Mount Sinai Hospital, New York, NY, USA

    Annapoorna S. Kini

  4. Duke University, Durham, NC, USA

    Sunil V. Rao

  5. MedStar Washington Hospital Center, Washington, DC, USA

    William Weintraub

  6. Cedars-Sinai Heart Institute, Los Angeles, CA, USA

    Timothy D. Henry

  7. Intermountain Heart Institute, Salt-Lake City, UT, USA

    Joseph B. Muhlestein

  8. Christiana Care Health System, Newark, DE, USA

    Sandra Weiss

  9. Minneapolis Heart Institute, Minneapolis, MN, USA

    Craig Strauss

  10. University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Catalin Toma

  11. Aurora Cardiovascular Services, Milwaukee, WI, USA

    Anthony DeFranco

  12. Eli Lilly and Company, Indianapolis, IN, USA

    Stuart Keller & Mark B. Effron

  13. Daiichi Sankyo, Inc, Parsippany, NJ, USA

    Brian A. Baker

  14. John Ochsner Heart and Vascular Center, Ochsner Medical Center, New Orleans, LA, USA

    Mark B. Effron

  15. London School of Hygiene and Tropical Medicine, London, UK

    Stuart Pocock

  16. Cleveland Clinic, Cleveland, OH, USA

    Samir Kapadia

Authors
  1. Jaya Chandrasekhar
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  2. Usman Baber
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  3. Samantha Sartori
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  4. Melissa Aquino
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  5. Kamilia Moalem
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  6. Annapoorna S. Kini
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  7. Sunil V. Rao
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  8. William Weintraub
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  9. Timothy D. Henry
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  10. Birgit Vogel
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  11. Zhen Ge
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  12. Joseph B. Muhlestein
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  13. Sandra Weiss
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  14. Craig Strauss
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  15. Catalin Toma
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  16. Anthony DeFranco
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  17. Bimmer E. Claessen
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  18. Stuart Keller
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  19. Brian A. Baker
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  20. Mark B. Effron
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  21. Stuart Pocock
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  22. George Dangas
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  23. Samir Kapadia
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  24. Roxana Mehran
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Corresponding author

Correspondence to Roxana Mehran.

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Chandrasekhar, J., Baber, U., Sartori, S. et al. Prasugrel use and clinical outcomes by age among patients undergoing PCI for acute coronary syndrome: from the PROMETHEUS study. Clin Res Cardiol 109, 725–734 (2020). https://doi.org/10.1007/s00392-019-01561-4

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  • DOI: https://doi.org/10.1007/s00392-019-01561-4

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