Potent P2Y12 receptor inhibitors, such as prasugrel and ticagrelor, have been tested mainly in a setting of acute coronary syndromes. There is little evidence on stable patients, particularly for prasugrel. Designing a study with that purpose seemed challenging enough, but adding aspirin discontinuation in patients without a particularly high bleeding risk took this research to another level.
The working hypothesis was that prasugrel monotherapy after successful angioplasty with an everolimus-eluting stent could be safe and effective in a population with stable coronary disease.
The most recent papers have pushed a short or ultra-short aspirin use time in patients with an overall high bleeding risk.
This paper, published in JACC Cardiovasc Interv., took it a step further by skipping aspirin altogether in a low-risk population (SYNTAX score <23) who underwent elective angioplasty.
All patients were receiving dual antiplatelet therapy at the time of the procedure (even on the actual day it was conducted), and aspirin was discontinued immediately after successful angioplasty. Prasugrel was administered in the cath lab immediately after the procedure and was continued as monotherapy for only 3 months.
The primary endpoint was a composite of cardiac death, vessel-related infarction, definite thrombosis, and major bleeding (Bleeding Academic Research Consortium types 3 to 5).
Of 201 enrolled patients, there was an event in one patient (0.5%). There were no cases of stent thrombosis.
Prasugrel monotherapy after successful elective angioplasty with everolimus-eluting stent in a population with simple anatomy proved safe and effective. These findings promote designing higher-scale studies to define the right balance between ischemic and hemorrhagic risk.
Original Title: Aspirin-Free Prasugrel Monotherapy Following Coronary Artery Stenting in Patients With Stable CAD. The ASET Pilot Study.
Reference: Norihiro Kogame et al. JACC Cardiovasc Interv. 2020 Oct 12;13(19):2251 2262. doi: 10.1016/j.jcin.2020.06.023.