Prasugrel pretreatment ups bleeding risk in NSTE ACS

Current guidelines recommend dual antiplatelet therapy with aspirin and a P2Y₁₂ inhibitor to inhibit platelet activation and thereby prevent recurrent ischemia in patients with NSTE myocardial infarction who are undergoing PCI, and prasugrel is among the agents available to complement aspirin.

Prasugrel is known to be effective in this setting, but "our knowledge about the administration of dual antiplatelet therapy remains incomplete," Dr. John F. Keaney Jr. wrote in an editorial. He noted that the timing for starting P2Y₁₂ inhibition has been unclear.

In this study, Dr. Montalescot and colleagues offer new insight into the timing of prasugrel administration, and the findings highlight the difference between first- and second-generation P2Y₁₂ inhibitors – namely, prasugrel "undergoes more efficient metabolism, producing faster and more complete platelet inhibition," he said.

The findings may streamline care in patients with NSTEMI in the hospital, he said, explaining that reserving prasugrel administration until after angiography, as indicated in this study, allows it to be limited to patients who will undergo PCI. This, in turn, will prevent the delays in treatment common among NSTEMI patients undergoing CABG who have received P2Y₁₂ antagonist treatment soon after hospital admission per current guidelines, and who must wait 5-7 days after P2Y₁₂ antagonist treatment before the procedure can be performed, due to the risk of excess bleeding.

Dr. Keaney is an associate editor for the New England Journal of Medicine. He reported having no other disclosures. Dr. Keaney is professor of medicine at the University of Massachusetts, and chief of the division of cardiovascular medicine at UMass Memorial Medical Center, both in Worcester. Dr. Keaney’s editorial was published with the article by Dr. Montalescot and his associates (N. Engl. J. Med. 2013 Sept. 1 [doi:10.1056/NEJMe1308820]).