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The Killip classification in prediction of laboratory efficacy Of P2Y12 receptor inhibitors in patients with STE myocardial infarction
Authors : Z Motovska (Prague,CZ), J Knot (Prague,CZ), M Ondrakova (Prague,CZ), J Ulman (Prague,CZ), F Bednar (Prague,CZ), M Maly (Prague,CZ), P Widimsky (Prague,CZ)
Z. Motovska1
,
J. Knot1
,
M. Ondrakova1
,
J. Ulman1
,
F. Bednar1
,
M. Maly2
,
P. Widimsky1
,
1Charles University Prague, 3rd Faculty of Medicine, Faculty Hospital Kralovske Vinohrady - Prague - Czech Republic
,
2National Institute of Public Health - Prague - Czech Republic
,
Background: High-risk patients with STE myocardial infarction (STEMI) and cardiogenic shock were excluded from large-scale randomized studies (PLATO, TRITON) comparing clinical efficacy and safety of oral P2Y12 inhibitors.
Purpose: The study aimed to investigate impact of Killip classification on laboratory efficacy of P2Y12 inhibitors in patients with STEMI treated with primary PCI.
Methods: 429 patients with STEMI and detailed data on Killip class at presentation, who were included in the LAPCOR (Laboratory AntiPlatelet efficacy and Clinical Outcome Registry; ClinicalTrials.gov NCT02264912) registry, represent the study population. Efficacy of P2Y12 inhibitors was measured by VASP phosphorylation 24±4 hours after a loading dose of clopidogrel (600 mg, N=210), prasugrel (60 mg, N=120), or ticagrelor (180 mg, N=99) and expressed by platelet reactivity index (PRI). High on-treatment platelet reactivity HTPR was defined as PRI≥50%. Laboratory efficacy of P2Y12 inhibitors was compared between patients with (5.2% of study population; age mean (SD) 65.3 (14.8), 36.4% women) and without cardiogenic shock (age 62.5 (12.9), 30.7% women).
Results: Residual platelet reactivity was significantly higher in clopidogrel-treated patients with Killip class 4 in comparison to patients with Killip class <4 (PRI mean (SD) 61.4 (17.2)% vs. 44.4 (22.6)%, P=0.028). The significance of difference was confirmed after correction for baseline confounding characteristics (age, gender, diabetes, hypertension, renal dysfunction) with P value after adjustment=0.013. HTPR was detected in 66.7% of patients with Killip class 4 receiving clopidogrel (vs. 41.4% of Killip <4). No difference in efficacy of ticagrelor was observed between patients with and those without Killip class 4 (PRI mean (SD) 28.2 (14.4) vs. 19.0 (15.6)%, n.s.). All patients with cardiogenic shock initiated on ticagrelor had PRI<50%. In the prasugrel group, residual platelet reactivity was significantly higher in patients with Killip class 4 in comparison to patients with Killip <4 (PRI mean (SD) 35.5 (30.8)% vs. 17.6 (17.6)%, p=0.015. This difference became non-significant after adjusting for confounding variables with P value after adjustment=0.1. The probability to have HTPR in patients initiated on prasugrel with Killip class 4 did not differ significantly from those with Killip class <4 (Odds Ratio 4.6, 95% C.I. 0.8 27.3).
Conclusion: New P2Y12 receptor inhibitors are effective in patients with STEMI irrespective of Killip class at presentation. Clopidogrel should be avoided in this high-risk population, especially in patients with cardiogenic shock.
In line with the ESC mission, newly presented content is made available to all for a limited time (4 months for ESC Congress, 3 months for other events). ESC Professional Members, Association Members (Ivory & above) benefit from year-round access to all the resources from their respective Association, and to all content from previous years. Fellows of the ESC (FESC), and Professionals in training or under 40 years old, who subscribed to a Young Combined Membership package benefit from access to all ESC 365 content from all events, all editions, all year long. Find out more about ESC Memberships here.