Background: Prasugrel has proved its superiority to clopidogrel for reducing ischemic events among patients with acute coronary syndromes undergoing percutaneous coronary intervention (PCI). However, in patients receiving thrombolysis for ST-elevation myocardial infarction (STEMI) guidelines recommend the use of clopidogrel, rather than prasugrel in addition to aspirin. The switch to prasugrel after a loading dose of clopidogrel following thrombolysis and prior to subsequent PCI has not been addressed.
We examined the in-hospital safety of loading and maintenance therapy with prasugrel in STEMI patients who were loaded with clopidogrel concomitantly with thrombolysis and transferred to a PCI-capable hospital.
Methods: We reviewed consecutive STEMI patients from 02/2011 to 01/2013 who were transferred to our hospital after receiving thrombolysis and a loading dose of clopidogrel in a non-PCI-capable center. If not contraindicated, these patients were loaded and treated with prasugrel 24-48 hours after thrombolysis. A control group, 3 times larger, was randomly selected from patients who initially arrived at our hospital, underwent primary PCI and were treated with prasugrel alone. Adjunctive anticoagulant and antiplatelet regimens were at the operator’s discretion.
Results: Cases (n=30, 16.7% female, mean age 55.3 years) and controls (n=97, 10.3% female, mean age 54.4 years) did not differ with respect to age, gender, MI location, left ventricular systolic function and extant of coronary artery disease. No significant differences were found between cases and controls in TIMI major (0% vs. 1%) and minor bleeding (0% vs. 3%), overall mortality (0% vs. 1%), and total hospitalization length (4.8±1.3 vs. 5.3±2 days).
Conclusion: Loading and subsequent maintenance therapy with prasugrel in patients who received thrombolysis and a loading dose of clopidogrel 24-48 hours earlier appears to be as safe as in STEMI patients managed by primary PCI. Prasugrel should not be denied to patients who receive thrombolysis.
