BACKGROUND: The impact of the most potent P2Y12i ticagrelor and prasugrel after acute coronary syndrome in patients with chronic kidney disease (CKD) remains unclear. Indeed, this condition is associated to both higher thrombotic and hemorragic risk, as a consequence newer P2Y12i are seldom used. Most evidence comes from real-world study but is limited to GFR under 60 ml/min whereas no data are available regarding patients with severe CKD (stages IV-V)
METHODS: Consecutive patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) and severe CKD defined as GFR under 30 ml/min not on dialysis from the CORALYS (Incidence and Predictors of Heart Failure After Acute Coronary Syndrome) registry were included. Incidence of Net Clinical Adverse Events (NACE) defined as MACE (a composite of cardiovascular death, myocardial infarction and unplanned revascularizations) in addition to major bleedings (classified as BARC 3-5) was our primary endpoint. MACE and their single components, all bleedings, major bleedings and hospitalizations for heart failure were the secondary ones.
RESULTS: Of 14699 patients in the CORALYS registry, 257 presented with severe CKD not on dialysis and had available data on antiplatelet regimen at discharge. Patients were divided into two groups according to the type of P2Y12i prescribed at discharge: 193 (75.1%) were given clopidogrel while 64 (24.9%) with ticagrelor or prasugrel. Our cohort was predominantly male (153, 59.5%) with an average age 75.8 ± 10.9 years old. Average GFR was 21.8 ± 6.3 ml/min.
Over a median follow-up of 459 days. Ticagrelor and Prasugrel were associated to lower rates of NACE compared to Clopidogrel, driven by an excess of CV mortality and myocardial infarction (77 (39.9%) vs 16 (25.0%), Adj Hr 0.41 95%CI 0.23-0.74, p=0.03). No difference was reported regarding overall bleeding events (5.7% vs 4.6% with clopidogrel and new P2Y12i respectively, p=0.81) and major bleedings 1.7% vs 4.6% with clopidogrel and new P2Y12i respectively, p=0.15).
CONCLUSIONS: In ACS patients treated with PCI with severe CKD ticagrelor and prasugrel were associated to lower risk of NACE, MACE, CV death and myocardial infarction compared to clopidogrel. Regarding bleedings, no significative difference was reported despite a relative increase of major bleedings in the group treated with newer P2Y12i