Insides : 40%-60% of patients with acute coronary syndrome with non ST elevation (ACS) are treated clinically. Prasugrel proved superior to clopidogrel in patients with ACS undergoing invasive treatment (TRITON-TIMI 38). The TRILOGY ACS randomized multicenter trial assessed prasugrel and clopidogrel in patients with ACS treated clinically. Study results were neutral and have already been presented at the European Congress of Cardiology 2012. This time, authors assessed the impact of angiography within the comparative effect of both drugs.
Methods and Results: Methods and Results: A total of 9,326 patients were included, 3,085 (43%) with angiography and 4,158 (57%) without angiography. By protocol, in the case of having a prior angiogram, inclusion criterion required the presence of a stenotic lesion >30% or previous history of coronary revascularization. In the invasive strategy group, prasugrel reduced by 23% (p = 0.031) the primary endpoint (death, MI or stroke), while in the conservative group, there were no differences between the drugs (p = 0.954). In the peak invasive group, prasugrel was associated with a trend to increased bleeding compared with clopidogrel (p = 0.07).
Conclusions: Prasugrel was not superior to clopidogrel in the TRILOGY ACS trial except in patients with coronary angiographic diagnosis. It is possible that angiography has guaranteed the presence of coronary artery disease (and probably a higher risk) compared to patients without angiography. Thus, patients with a higher risk tend to benefit most from prasugrel than patients with a lower risk.
Stephen D. Wiviott.
2012-10-24
Original title: TRILOGY ACS Angiographic Cohort: A Prospective, Randomized Trial of Prasugrel vs. Clopidogrel in Patients with Non-ST-Segment Elevation ACS Who Are Medically Managed After Coronary Angiography
