Author + information
- Received July 13, 2017
- Revision received August 17, 2017
- Accepted August 29, 2017
- Published online December 18, 2017.
- Pierre Deharo, MDa,b,c,
- Jacques Quilici, MDd,
- Laurence Camoin-Jau, MD, PhDe,
- Thomas W. Johnson, MDf,
- Clémence Bassez, MDa,c,
- Guillaume Bonnet, MDa,c,
- Marianne Fernandez, MDd,
- Manal Ibrahim, MDc,g,
- Pierre Suchon, MDc,h,
- Valentine Verdier, MDh,
- Laurent Fourcade, MD, PhDg,
- Pierre Emmanuel Morange, MD, PhDb,c,e,i,
- Jean Louis Bonnet, MD, PhDa,b,c,
- Marie Christine Alessi, MD, PhDb,c,e,i and
- Thomas Cuisset, MD, PhDa,b,c,∗ ()
- aDépartement de Cardiologie, CHU Timone, Marseille, France
- b“Nutrition, Obesity and Risk of Thrombosis,” UMR1062, INSERM, Marseille, France
- cFaculté de Médecine, Aix-Marseille Université, Marseille, France
- dDepartement de Cardiologie, Centre Hospitalier de GAP, France
- eLaboratoire d’Hématologie, CHU Timone, Marseille, France
- fInterventional Cardiology Department, Bristol Heart Institute, Bristol, United Kingdom
- gCardiologie, Hôpital Laveran, Marseille, France
- hResearch Unit, asistance publique des hopitaux de Marseille, Unité Médicale des Maladies Auto-Inflammatoires, Marseille, France
- iDepartment of Hematology, CHU Timone, asistance publique des hopitaux de Marseille, Marseille, France
- ↵∗Address for correspondence:
Dr. Thomas Cuisset, Department of Cardiology, Hôpital la Timone, 13005 Marseille, France.
Objectives This study sought to evaluate the impact of initial platelet reactivity on the benefit of switched strategy.
Background TOPIC (Timing Of Platelet Inhibition after acute Coronary Syndrome) study suggested that switched dual antiplatelet therapy (DAPT) could improve net clinical benefit after acute coronary syndrome by preventing bleeding.
Methods Acute coronary syndrome patients, 1 month after coronary stenting and event free, were randomly assigned to aspirin and clopidogrel (switched DAPT) or continuation of drug regimen (unchanged DAPT). All patients underwent platelet function testing at this time and were classified as low on-treatment platelet reactivity (LTPR) (platelet reactivity index vasodilator-stimulated phosphoprotein ≤20%) or non-LTPR (platelet reactivity index vasodilator-stimulated phosphoprotein >20%). The primary endpoint aimed to evaluate the impact of platelet reactivity on clinical outcomes and benefit of switched DAPT strategy.
Results A total of 645 patients were included, 305 (47%) of whom were classified as LTPR. LTPR patients were less often diabetic (p = 0.01), had lower body mass index (p < 0.01), and were more often on ticagrelor (p < 0.01). Patients defined as LTPR and randomized to unchanged DAPT were at the highest risk of primary endpoint occurrence (31%; p < 0.01). Conversely, in the switched arm, LTPR patients had no significant difference in primary outcome incidence compared with non-LTPR patients (hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.40 to 1.49; p = 0.45). The switched strategy was associated with important reduction in primary endpoint incidence in LTPR patients (HR: 0.29; 95% CI: 0.17 to 0.51; p < 0.01) and only numerically lower incidence in non-LTPR patients (HR: 0.79; 95% CI: 0.46 to 1.35; p = 0.39).
Conclusions Switched DAPT was superior regardless of initial platelet reactivity but the benefit was greater in LTPR patients. Indeed, the switched strategy was highly effective in this group, which had impaired prognosis with unchanged DAPT but similar prognosis after switching.
This work was supported by Assistance-Publique-Hôpitaux-de-Marseille. Dr. Deharo has received personal fees from Sanofi. Dr. Johnson has received personal fees from Abbott Vascular, AstraZeneca, Boston Scientific, Correvio, Daiichi-Sankyo, St. Jude Medical, Terumo, and The Medicines Company. Dr. Cuisset has received personal fees from AstraZeneca, Boston Scientific, Biotronik, Eli Lilly, Medtronic, Sanofi, and Terumo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 13, 2017.
- Revision received August 17, 2017.
- Accepted August 29, 2017.
- 2017 American College of Cardiology Foundation