This very interesting work leaves us with a sour taste in our mouth, as it failed to meet its primary endpoint. Using genotype to individualize treatment with a P2Y12 inhibitor in patients with acute coronary syndrome or stable patients after a scheduled angioplasty compared with conventional treatment with clopidogrel does not reduce the risk of ischemic events at 12 months. This is another nice theory that crashes and burns against reality.
Many people expected this work to provide a definitive answer on the efficacy of knowing patient genotype, after the publication of POPular Genetics a few months back showing the noninferiority of a genotype-guided strategy vs. treatment with ticagrelor or prasugrel, but without such information.
At 1 year, there was a 34% reduction in the combined endpoint (cardiovascular death, infarction, stroke, definite or probable stent thrombosis, and severe recurrent ischemia) with a strategy guided by genotype (basically, the identification of a CYP2C19 loss-of-function allele) compared with a conventional strategy with clopidogrel (4.0% vs. 5.9%; hazard ratio [HR]: 0.66; 95% confidence interval [CI]: 0.43-1.02). Such 34% is not statistically significant, since the target was 50%.
Reference: Pereira N et al. Presentado en forma virtual en el ACC 2020.
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