Effects of potent P2Y12 inhibitors in patients who survived from acute myocardial infarction complicated by cardiogenic shock

Although two pivotal trials including PLATO and TRITON-TIMI 38 consistently demonstrated that the ischemic benefits of potent P2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel in patients with acute myocardial infarction (AMI), those trials exclude patients with AMI complicated by cardiogenic shock (AMI-CS). Therefore, the benefits and risks associated with potent P2Y12 inhibitors vs clopidogrel in AMI-CS survivors merits attention.

The current study aimed to compare the ischemic and bleeding outcomes between potent P2Y12 inhibitor-based dual antiplatelet therapy (DAPT) vs. clopidogrel-based DAPT in successfully discharged patients with AMI-CS.

This was a population-based, nationwide, cohort study from the Korean National Health Insurance Service database. We included 14,268 patients with AMI-CS admitted to a percutaneous coronary intervention (PCI)-capable center between January 2012 and March 2023 and successfully discharged with prescription of DAPT. Patients were matched using a large-scale propensity score (PS) algorithm according to the P2Y12 inhibitor type. The primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE), as a composite of all-cause death, MI, and stroke. The primary safety outcome was major bleeding requiring transfusion.

Among the total population, 59.9% (N=8,542) received clopidogrel and the remaining 40.1% (N=5,726) received ticagrelor or prasugrel as their discharge medication with aspirin. After PS matching, 3,752 pairs were generated. At the 1-year follow-up, MACCE occurred in 344 patients in the clopidogrel group and in 286 patients in the ticagrelor or prasugrel group, with corresponding incidence rates of 9.2% and 7.7%, respectively (HR:0.82; 95%CI:0.70-0.96). The 1-year incidence of major bleeding requiring transfusion was numerically higher in the ticagrelor or prasugrel group than in the clopidogrel group (1.1% vs. 1.3%; HR:1.17; 95%CI:0.76-1.79), but this was not statistically significant.

In real-world data from a large study of East Asian patients with AMI-CS who successfully discharged with maintaining DAPT after PCI, use of potent P2Y12 inhibitors such as prasugrel or ticagrelor was associated with significantly lower risk of ischemic events without increasing bleeding events.