Background: In the ACCOAST trial, pretreatment with prasugrel 30mg did not provide an ischemic benefit in patients with non-ST elevation myocardial infarction (NSTEMI) but increased bleeding. The evaluation of pretreatment duration (time from randomization to angiography) on outcomes is presented in this analysis.
Methods: The 4033 NSTEMI patients enrolled in the ACCOAST trial were divided into quartiles of duration of pretreatment (Q1= 0.07-2.5 hours; Q2= 2.5-3.89 hours, Q3= 3.89-13.6 hours and Q4 > 13.6 hours) with an evaluation of the primary efficacy (a composite of cardiovascular death, myocardial infarction, stroke, urgent revascularization or GPIIb/IIIa bailout) and key safety outcomes (all CABG or non-CABG TIMI major bleeding) at 7 days.
Results: The primary efficacy outcome and the primary safety key outcomes did not differ between the groups of patients with shorter or longer duration of pretreatment p= 0.17 and 0.38 for interaction, respectively. Longer duration of pretreatment was associated with a stepwise decrease in the secondary endpoint of urgent revascularization (Q1= HR 1.49 ; Q2= HR 0.76 ; Q3= HR 0.56 ; Q4= HR 0.27 ; p=0.03 for interaction (Figure) but did not impact the others secondary endpoints. Results were similar for the PCI patients (69% of the population). All results were confirmed at 30 days.
Conclusions: In NSTEMI patients managed invasively, shorter or longer pretreatment duration with prasugrel did not impact significantly ischemic events or major bleeding complications in the ACCOAST trial, with the possible exception of urgent revascularization.