COMPARE CRUSH: A randomized trial of prehospital crushed vs uncrushed prasugrel in STEMI
Reported from the TCT Congress 2020
Luis Ortega-Paz provides a summary of the key messages from the COMPARE CRUSH trial. He also discusses the main findings and recommendations in clinical practice with Georgios Vlachojannis who presented the results during TCT Connect 2020.
Background: The impact on coronary reperfusion of crushed P2Y12 inhibitor tablets, which lead to more prompt and potent platelet inhibition, is unknown.
Hypothesis: Patients presenting with STEMI planned for primary PCI will have improved markers of optimal reperfusion and clinical outcomes by pre-hospital administration of crushed tablets of the prasugrel loading dose.
Objective: To assess the efficacy of pre-hospital administration of crushed tablets of a loading dose of prasugrel in improving coronary reperfusion markers in STEMI patients planned for primary percutaneous cardiac intervention (pPCI).
Methods1:
- Randomized controlled, multicenter trial in the Netherlands, enrolling STEMI patients planned to undergo pPCI.
- Randomly allocated to receive in the ambulance, before the transfer, a 60 mg loading dose (LD) of prasugrel either as crushed or integral tablets.
- Independent primary endpoints were thrombolysis in myocardial infarction (TIMI) 3 flow in the infarct-related artery (IRA) at initial coronary angiography, and complete (≥70%) ST-segment resolution one-hour post-pPCI.
- The safety endpoints were TIMI major and bleeding academic research consortium (BARC) ≥3 bleedings. Secondary endpoints included platelet reactivity and ischemic outcomes.
Results2:
- A total of 727 patients were assigned to either crushed or integral tablets of prasugrel LD.
- The primary endpoint TIMI 3 flow in the IRA pre-pPCI occurred in 31.0% in the crushed group vs. 32.7% in the integral group. Complete ST-segment resolution one-hour post-pPCI was present in 59.9% in the crushed group vs. 57.3% in the integral group.
- Platelet reactivity at the beginning of pPCI, measured as P2Y12 reactivity unit, was lower in the patients assigned to crushed prasugrel
- There were no differences between groups in bleeding events.
Conclusions:
- In STEMI patients, pre-hospital administration of crushed prasugrel loading dose before pPCI did not improve the TIMI flow of the IRA or ST-segment resolution.
Interview with Georgios Vlachojannis
Insights from the author
"I would like to underline an important aspect of the COMPARE CRUSH trial. This trial was performed to assess the maximum efficacy of oral P2Y12 inhibitors in the acute phase STEMI by the administration of the P2Y12 inhibitors in the most favourable pharmacodynamic formulation (i.e., crushed) and at the earliest possible time point (i.e., first medical contact). And despite we see that crushed tablets have a significant favourable impact on platelet inhibition compared with integral tablets, there is still a considerable proportion of patients (42% in the crushed group vs. 63% in the integral group) who have high platelet reactivity at the beginning of the PCI procedure. Thus it appears unlikely that oral P2Y12 inhibitors will be able to bridge the gap in platelet inhibition during the acute phase of STEMI. Whether faster and more potent platelet inhibition with parenteral antiplatelet agents in addition to the contemporary STEMI treatment regimen can improve early coronary reperfusion warrants further investigation."
References
- Vlachojannis GJ, Vogel RF, Wilschut JM, Lemmert ME, Delewi R, Diletti R, van Vliet R, van der Waarden N, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Van Mieghem NM, Smits PC. Comparison of pre-hospital crushed vs. Uncrushed prasugrel tablets in patients with stemi undergoing primary percutaneous coronary interventions: Rationale and design of the compare crush trial. Am Heart J. 2020;224:10-16
- Vlachojannis GJ, Wilschut JM, Vogel RF, Lemmert ME, Delewi R, Diletti R, Waarden NWPLvd, Nuis R-J, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Mieghem NMV, Smits PC. Effect of pre-hospital crushed prasugrel tablets in patients with stemi planned for primary percutaneous coronary intervention: The randomized compare crush trial. Circulation.
Related links
- COMPARison of pre-hospital CRUSHed vs. uncrushed Prasugrel tablets in patients with STEMI undergoing primary percutaneous coronary interventions: Rationale and design of the COMPARE CRUSH trial
- Effect of Pre-Hospital Crushed Prasugrel Tablets in Patients with STEMI Planned for Primary Percutaneous Coronary Intervention: The Randomized COMPARE CRUSH Trial
#CardioPoll
#TCTConnect@PCRonline#EAPCI After the COMPARE crush results, what will be your strategy for STEMI patients? @EuroInterventio@escardio@TCTConference@TCTMD@GVlachojannishttps://t.co/KVe6HZBIIO
— Luis Ortega Paz (@Ortega_Paz) October 15, 2020
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