Reducing Microvascular Dysfunction in Revascularized Patients with ST-Elevation Myocardial Infarction by Off-Target Properties of Ticagrelor versus Prasugrel. Rationale and Design of the REDUCE-MVI Study

Gladys N Janssens, Maarten A H van Leeuwen, Nina W van der Hoeven, Guus A de Waard, Robin Nijveldt, Roberto Diletti, Felix Zijlstra, Clemens von Birgelen, Javier Escaned, Marco Valgimigli, Niels van Royen, Gladys N Janssens, Maarten A H van Leeuwen, Nina W van der Hoeven, Guus A de Waard, Robin Nijveldt, Roberto Diletti, Felix Zijlstra, Clemens von Birgelen, Javier Escaned, Marco Valgimigli, Niels van Royen

Abstract

Microvascular injury is present in a large proportion of patients with ST-elevation myocardial infarction (STEMI) despite successful revascularization. Ticagrelor potentially mitigates this process by exerting additional adenosine-mediated effects. This study aims to determine whether ticagrelor is associated with a better microvascular function compared to prasugrel as maintenance therapy after STEMI. A total of 110 patients presenting with STEMI and additional intermediate stenosis in another coronary artery will be studied after successful percutaneous coronary intervention (PCI) of the infarct-related artery. Patients will be randomized to treatment with ticagrelor or prasugrel for 1 year. FFR-guided PCI of the non-infarct-related artery will be performed at 1 month. Microvascular function will be assessed by measurement of the index of microcirculatory resistance (IMR) in the infarct-related artery and non-infarct-related artery, immediately after primary PCI and after 1 month. The REDUCE-MVI study will establish whether ticagrelor as a maintenance therapy may improve microvascular function in patients after revascularized STEMI.

Trial registration: ClinicalTrials.gov NCT02422888.

Keywords: Adenosine; Microvascular injury; Prasugrel; ST-elevation myocardial infarction; Ticagrelor.

Figures

Fig. 1
Fig. 1
Flow chart of the REDUCE-MVI study. CMR cardiovascular magnetic resonance, IMR index of microcirculatory resistance, OCT optical coherence tomography, PCI percutaneous coronary intervention, RHI reactive hyperemia index, STEMI ST-elevation myocardial infarction
Fig. 2
Fig. 2
Primary PCI procedure with subsequentmeasurement of the IMR. a Angiographic demonstration of the presence of a subtotal occlusion of the right coronary artery (RCA) in its mid portion and b final result after successful reopening of the RCA with subsequent implantation of two DES stents; c measurement of the IMR. The recording is obtained from a pressure wire in the mid of the right coronary artery of a patient after primary PCI. The panel is divided into two windows; the upper window displays the pressure segments recorded during each saline injection, separated from each other by white vertical lines (mean proximal arterial pressure (Pa) = 91 and mean distal arterial pressure (Pd) = 81 result into a fractional flow reserve (FFR) = 0.89). The lower graph displays saline injections at baseline (blue) and during hyperemia (yellow). Between the two graphs are mean transit time values at baseline (preceded by “Bas”), and during hyperemia (preceded by “Hyp”)

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