Prehospital Crushed vs. Integral Prasugrel in STEMI Patients with Large Myocardial Area at Risk

Timely percutaneous intervention of STEMI patients effectively reduces MI size and mortality, which currently makes it the first line of treatment. A fundamental aspect is activation and platelet aggregation, which is why, in addition to creating networks to optimize STEMI treatment, prehospital drug treatments have been implemented.

The COMPARECrush looked at whether early and powerful treatment on platelet inhibition through crushed prasugrel in the ambulance might improve epicardial perfusion. Results showed a reduction in early platelet reactivity during primary PCI. However, it remains unclear whether platelet inhibition might benefit a subgroup of high risk patients.

The aim of this multicenter randomized study was to assess the efficacy of prehospital crushed vs. integral prasugrel loading dose in patients with large myocardial area at risk, reflected by the accumulated ST deviation at ambulance ECG.

Primary end point included flow TIMI 3 in the infarct related artery, high thrombus load and grade 3 blush. The study also looked at clinical outcomes such as all-cause mortality, repeat MI, stent thrombosis, use of IIb/IIIa, stroke and emergency revascularization.

532 patients were included, 62% presenting a large myocardial area at risk. Mean age was 61 in the group of large myocardia area at risk, vs. 63 in the group without large myocardial compromise. Most were men. The most affected artery was the anterior descending, followed by the circumflex and the right coronary artery.

Crushed prasugrel significantly improved postprocedural TIMI 3 in STEMI patients with large prehospital myocardial area at risk (92 % vs 79 %, OR: 3,00, CI 95%: 1,50-6,00), but not in patients with STEMI without a large prehospital myocardial area at risk (91 % vs 95 %, OR 0,47; CI 95 %: 0,14-1,57; interaction = 0,009). There were no differences in clinical outcomes between the groups.

Conclusion

This substudy showed a significant effect of prehospital crushed vs integral prasugrel in terms of procedural success in patients with STEMI and a large myocardial area at risk. This finding was reflected by improved final TIMI 3 flow, and represents a fast and cost effective strategy. Even though these data come from a substudy, they should generate hypothesis for future studies.