Efficacy and Safety of Clopidogrel, Prasugrel and Ticagrelor in ACS Patients Treated with PCI: A Propensity Score Analysis of the RENAMI and BleeMACS Registries.

INTRODUCTION: Real-life data comparing clopidogrel, prasugrel, and ticagrelor for unselected patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) are lacking, as are data for the temporal distribution of ischemic and bleeding risks. METHODS: A total of 19,825 patients were enrolled from the RENAMI and BleeMACS registries. Both were multicenter, retrospective, observational registries including the data and outcomes of consecutive patients with ACS who underwent primary PCI and were discharged with dual antiplatelet therapy (DAPT). We evaluated the long-term outcome stratified by the different antiplatelet agents. RESULTS: A total of 14,105 patients (71.2%) were treated with clopidogrel, 2364 patients (11.9%) with prasugrel and 3356 patients (16.9%) with ticagrelor. After propensity score matching, at 1 year, prasugrel reduced the incidence of net adverse clinical events (NACE; a composite endpoint of all-cause death, myocardial infarction [MI] and Bleeding Academic Research Consortium [BARC] 3-5 bleeding) (4.2% vs.7.6%, p = 0.002) and of major adverse cardiovascular events (MACE; a composite endpoint of death and MI) compared with clopidogrel (2.6% vs. 5.2%, p = 0.007). Ticagrelor decreased rates of MACE compared with clopidogrel (2.7% vs. 6.2%, p < 0.001), but not of NACE (6.6% vs. 8.7%, p = 0.07). Ticagrelor presented similar performance in terms of MACE compared with prasugrel (2.8% vs. 2.4%, p = 0.56), with a trend towards a reduction in MI (0.2% vs. 0.4%, p = 0.56), but with higher risk of BARC 3-5 bleedings (3.8% vs. 1.7%, p = 0.04). In the daily risk analysis, clopidogrel presented a binomial distribution with a peak of ischemic risk at 3 months, which decreased towards bleedings; prasugrel had a constant equivalence between opposite risks; and ticagrelor constantly reduced recurrent MIs despite higher risk of BARC 3-5 events. CONCLUSION: In real life, ticagrelor is more effective in reducing ischemic events during the first year after ACS, despite an increased risk of major bleedings, while prasugrel assures a better balance between ischemic and bleeding recurrent events.

Usefulness of neopterin levels and left ventricular function for risk assessment in survivors of acute myocardial infarction.

BACKGROUND: Results of previous studies have shown that serum neopterin levels are higher in patients with acute myocardial infarction (AMI). However, little is known regarding the prognostic value of neopterin in survivors of AMI. The present study analyzes the prognostic value of neopterin serum concentration and left ventricular ejection fraction in survivors of AMI. METHODS: The additional prognostic information provided by neopterin to parameters of left ventricular function in survivors of AMI was investigated through 82 patients with ST-segment elevation. RESULTS: Binary logistic regression analysis identified the following predictors of 6-month cardiac death: Killip class >I at presentation (OR=2.4, 95% CI: 1.2 to 3.8, p=0.001), a reduced ejection fraction (OR=1.9, 95% CI: 1.3 to 2.2, p=0.001), and greater neopterin (OR=1.4, 95% CI: 1.1 to 1.6, p=0.01). CONCLUSIONS: Neopterin is associated with mortality, in addition to parameters of ventricular function (Killip class and ejection fraction) in survivors of AMI.