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Associations between complex PCI and Prasugrel or Clopidogrel use in patients with acute coronary syndrome who undergo PCI: from the PROMETHEUS study
The Canadian journal of cardiology
  • Jaya Chandrasekhar
  • Usman Baber
  • Samantha Sartori
  • Melissa Aquino
  • Annapoorna S Kini
  • Sunil Rao
  • William Weintraub
  • Timothy D Henry
  • Serdar Farhan
  • Birgit Vogel
  • Sabato Sorrentino
  • Zhen Ge
  • Samir Kapadia
  • Joseph B Muhlestein
  • Sandra Weiss
  • Craig Strauss
  • Catalin Toma
  • Anthony DeFranco, Aurora Health Care
  • Mark B Effron
  • Stuart Keller
  • Brian A Baker
  • Stuart Pocock
  • George Dangas
  • Roxana Mehran
Aurora Affiliations

Aurora Cardiovascular Services

Publication Date


METHODS: PROMETHEUS was a multicentre observational study that compared clopidogrel vs prasugrel in acute coronary syndrome patients who underwent PCI (n = 19,914). Complex PCI was defined as PCI of the left main, bifurcation lesion, moderate-severely calcified lesion, or total stent length ≥ 30 mm. Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke, or unplanned revascularization. Outcomes were adjusted using multivariable Cox regression for effect of PCI complexity and propensity-stratified analysis for effect of thienopyridine type.

RESULTS: The study cohort included 48.9% (n = 9735) complex and 51.1% (n = 10,179) noncomplex patients. Second generation drug-eluting stents were used in 70.1% complex and 66.2% noncomplex PCI patients (P < 0.0001). Complex PCI was associated with greater adjusted risk of 1-year MACE (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.20-1.39; P < 0.001). Prasugrel was prescribed in 20.7% of complex and 20.1% of noncomplex PCI patients (P = 0.30). Compared with clopidogrel, prasugrel significantly decreased adjusted risk for 1-year MACE in complex PCI (HR, 0.79; 95% CI, 0.68-0.92) but not noncomplex PCI (HR, 0.91; 95% CI, 0.77-1.08), albeit there was no evidence of interaction (P interaction = 0.281).

CONCLUSIONS: Despite the use of contemporary techniques, acute coronary syndrome patients who undergo complex PCI had significantly higher rates of 1-year MACE. Adjusted magnitude of treatment effects with prasugrel vs clopidogrel were consistent in complex and noncomplex PCI without evidence of interaction.

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Chandrasekhar J, Baber U, Sartori S, et al. Associations Between Complex PCI and Prasugrel or Clopidogrel Use in Patients With Acute Coronary Syndrome Who Undergo PCI: From the PROMETHEUS Study. Can J Cardiol. 2018;34(3):319-329.