ACCOAST Substudy: Prasugrel Pretreatment Linked With Increased Bleeding in NSTEMI Patients

BARCELONA, Spain—Pretreatment with prasugrel before coronary angiography in patients with non-ST-segment elevation myocardial infarction (NSTEMI) is an additional risk factor for bleeding on top of already known procedural variables, according to a subanalysis of the ACCOAST trial presented on September 2, 2014, at the European Society of Cardiology Congress.

At 30 days, all TIMI major bleeding was higher in the pretreatment arm (2.9%) than the placebo arm (1.5%; P = .002). Incidence of any TIMI major or minor bleeding was 2.4% over 30 days, and 84% of these bleeds were presented in the first 7 days.

Median time from randomization to angiography did not differ between patients with and without non-CABG TIMI major bleeding. Older age, female sex, and low body weight were related to the risk of overall major bleeding, and hypertension enhanced the risk of major and minor non-CABG bleeding, especially in patients who underwent PCI. Additionally, use of multiple stents and GPIs were associated with more periprocedural bleeding complications, and transradial access twice as often in patients without bleeding (table 1).

Table 1. Factors Associated with Non-CABG TIMI Major Bleeding at 7 Days

Importantly, prasugrel pretreatment tripled the risks of non-CABG TIMI major (HR 3.02; 95% CI 1.42-6.43) and major or minor bleeding (HR 3.07; 95% CI 1.85-5.11) through 7 days. Other predictors of major bleeding included:

• Female sex (HR 2.56; 95% CI 1.32-5.00)
• Femoral access (HR 2.45; 95% CI 1.11-5.37)
• Multiple stents (HR 2.50; 95% CI 1.26-4.95)
• Age, per year (HR 1.05; 95% CI 1.02-1.09)

Within the PCI cohort, predictors of major bleeding were similar but also included switching from unfractionated heparin to low molecular weight heparin (HR 2.36; 95% CI 1.08-5.15). For major or minor bleeding, body weight was indirectly associated with risk (HR 1.03; 95% CI 1.01-1.05).

Discussant Kurt Huber, MD, of Wilhelminenhospital (Vienna, Austria), noted the importance of establishing prasugrel pretreatment as an additional bleeding risk factor in NSTEMI. In order to prevent bleeding, he said, “We need to stratify for bleeding risk, reduce dosage if necessary, and—if possible—avoid excessive dosing, avoid crossover of antithrombins, avoid antithrombotic combination therapies, eventually use safer antithrombotic agents, stop anticoagulants [during] sheath removal, use the radial vascular approach, and now avoid pretreatment with prasugrel in NSTEMI patients.”

Source: 
Widimský P. Predictors of bleeding in ACS patients treated with prasugrel: analysis from the ACCOAST study. Presented at: European Society of Cardiology Congress; September 2, 2014; Barcelona, Spain.

Disclosures:

• ACCOAST was supported by Daiichi Sankyo and Eli Lilly.
• Dr. Widimský reports receiving consultant fees and speaker honoraria from AstraZeneca, Bayer, Boehringer Engelheim, Daiichi Sankyo, Eli Lilly, and Sanofi.
• Dr. Huber reports receiving lecture fees from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly, Sanofi Aventis, and The Medicines Company.
  
  

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