Early Antiplatelet Therapy Escalation in STE-ACS Patients Treated with Primary PCI: Insights from the RENOVAMI Registry

Background: Switching from clopidogrel to newer generation P2Y12 inhibitors, such as prasugrel or ticagrelor, is a common practice in patients with ST-elevation acute coronary syndrome (STE-ACS) treated with primary percutaneous coronary intervention (PCI). Real-world data about this strategy, however, are limited.
Methods: From JAN 2012 to JAN 2015, 1057 consecutive STE-ACS patients treated with primary PCI in an Italian hub-and-spoke network were prospectively included in an observational registry (RENOVAMI, ClinicalTrials.gov Identifier: NCT01760382). We compared the prevalence, predictive factors and in-hospital outcomes of patients who switched from clopidogrel to a new generation antiplatelet drug within the first 24 hours from admission with those continuing on admission antiplatelet therapy.
Results: In the first 24 hours, 165 patients (15.6%) switched from clopidogrel to a new generation P2Y12 inhibitor. Drug eluting stent employment (adjusted OR 2.19, 95% CI 1.55 to 3.08, p=0.0002) and impaired renal function (adjusted OR 0.19, 95% CI 0.05 -0.77, p=0.02) were the only independent predictive factors for the decision to upgrade. After adjustment for potential confounders, switching to a new generation P2Y12 inhibitor did not predict in-hospital outcomes, whereas the overall use of new generation P2Y12 inhibitors was correlated with a better in-hospital survival (adjusted hazard ratio 0.47, 95% CI 0.25 to 0.91, P=0.03). Moreover switching to a new generation P2y12 inhibitor did not significantly influence bleeding rates.
Conclusions: In this prospective, hub-and-spoke registry of STE-ACS patients treated with primary PCI and contemporary antiplatelet therapy, early escalation to a new generation P2Y12 inhibitor appeared a safe practice and did not significantly affect in-hospital bleeding rates.