Mortality Benefit with Prasugrel in the TRITON-TIMI 38 Coronary Artery Bypass Grafting (CABG) Cohort: Risk-Adjusted Retrospective Data Analysis

• Type of Material: Article
• Authors: Peter K. Smith, Duke University; Lawrence T. Goodnough, Stanford University; Jerrold H Levy, Emory University; Robert S. Poston, University of Arizona; Mary A. Short, Lilly USA, LLC; Govinda J. Weerakkody, Lilly USA, LLC; LeRoy A. LeNarz, Lilly USA, LLC
• Language: English
• Date: 2012-07-31
• Publisher: Elsevier: 12 months
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.jacc.2012.03.030
• Title of Journal or Parent Work: Journal of the American College of Cardiology
• ISSN: 0735-1097
• Volume: 60
• Issue: 5
• Start Page: 388
• End Page: 396
• Grant/Funding Information: This work was sponsored by Daiichi Sankyo, Inc., Parsippany, NJ and Eli Lilly and Company, Indianapolis, IN and is related to study protocol H7T-MC-TAAL, listed on ClinicalTrials.gov; NCT 00097591.; Dr. Smith was supported by NHLBI U01-HL088953.
• Keywords: CLOPIDOGREL; MYOCARDIAL-INFARCTION; prasugrel; ST-SEGMENT ELEVATION; PLATELET INHIBITION; ASPIRIN; CARDIAC-SURGERY; Cardiac & Cardiovascular Systems; clopidogrel; mortality; acute coronary syndrome; BLEEDING COMPLICATIONS; INTERVENTION; Cardiovascular System & Cardiology; Life Sciences & Biomedicine; OUTCOMES; Science & Technology; coronary artery bypass grafting; FOCUSED UPDATE
• Research Categories: Health Sciences, Medicine and Surgery

Abstract

Objectives: The objective of this study was to characterize the bleeding, transfusion, and other outcomes of patients related to the timing of prasugrel or clopidogrel withdrawal before coronary artery bypass grafting (CABG). Background: There is little evidence to guide clinical decision making regarding the use of prasugrel in patients who may need urgent or emergency CABG. Experience with performing CABG in the presence of clopidogrel has raised concern about perioperative bleeding complications that are unresolved. Methods: A subset of the TRITON-TIMI 38 study (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel- Thrombolysis In Myocardial Infarction 38), in which patients with acute coronary syndrome were randomized to treatment with aspirin and either clopidogrel or prasugrel, underwent isolated CABG (N = 346). A supplemental case report form was designed and administered, and the data combined with the existing TRITON-TIMI 38 database. Baseline imbalances were corrected for using elements of the European System for Cardiac Operative Ri sk Evaluation and The Society of Thoracic Surgeons predictive algorithm. Results: A significantly higher mean 12-h chest tube blood loss (655 ± 580 ml vs. 503 ± 378 ml; p = 0.050) was observed with prasugrel compared with clopidogrel, without significant differences in red blood cell transfusion (2.1 U vs. 1.7 U; p = 0.442) or the total donor exposure (4.4 U vs. 3.0 U; p = 0.463). All-cause mortality was significantly reduced with prasugrel (2.31%) compared with 8.67% with clopidogrel (adjusted odds ratio: 0.26; p = 0.025). Conclusions: Despite an increase in observed bleeding, platelet transfusion, and surgical re-exploration for bleeding, prasugrel was associated with a lower rate of death after CABG compared with clopidogrel. (A Comparison of Prasugrel [CS-747] and Clopidogrel in Acute Coronary Syndrome Subjects Who Are to Undergo Percutaneous Coronary Intervention; NCT00097591)