Effects of Clopidogrel, Prasugrel and Ticagrelor on Microvascular Function and Platelet Reactivity in Patients With Acute Coronary Syndrome Undergoing Coronary Artery Stenting. A Randomized, Blinded, Parallel Group Trial

Boris Schnorbus, Kerstin Jurk, Karl J Lackner, Caroline Welk, Thomas Münzel, Tommaso Gori, Boris Schnorbus, Kerstin Jurk, Karl J Lackner, Caroline Welk, Thomas Münzel, Tommaso Gori

Abstract

Aims: In this pre-specified analysis of the "endothelium, stent and antiplatelet therapy" study, we investigate the impact of antiplatelet therapies on microvascular function in patients undergoing stenting for an acute coronary syndrome. Methods and Results: Fifty-six patients [age: 63(55-67) years, males, 10 diabetics, 27 non-ST-elevation myocardial infarction] were randomized to receive clopidogrel, ticagrelor or prasugrel in form of oral loading 2 h before stenting followed by oral therapy. Investigators were blinded to the allocation. Laser-Doppler microvascular function and ADP-induced platelet aggregation capacity were measured at baseline, 2 h after oral antiplatelet loading, and 1 day, 1 week and 1 month after stenting during chronic therapy with the same antiplatelet agent. Platelet aggregation decreased in all groups 2 h after oral loading, with a significantly larger effect in the prasugrel group (P = 0.009). Similarly, prasugrel and ticagrelor loading was followed by an increase in microvascular reactive hyperemia (P = 0.007 and P = 0.042 compared to clopidogrel). This effect disappeared one day after coronary intervention, with a significant decrease in the prasugrel group (P = 0.026). Similarly, analysis of microvascular conductance showed a larger increase in the prasugrel group 2 h after loading (P = 0.022 among groups), and a decrease in all groups after stenting. Conclusions: Oral loading with prasugrel (and less consistently ticagrelor) is associated with improved microvascular function and stronger platelet inhibition in acute coronary syndrome patients. The microvascular effect was however lost 1 day after stenting and during subsequent follow-up. Further studies are necessary to clarify the the long-term effects and potential benefits of P2Y12 inhibitors on microvascular damage. ClINICALTRIALS.gov N°: NCT01700322 EUDRACT-N°: 2011-005305-73.

Keywords: antiplatelet; coronary; microvascular (MV); randomized; stent.

Conflict of interest statement

TG has participated in symposia and meetings sponsored by Daiichi-Sankyo and by Astra Zeneca. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Schnorbus, Jurk, Lackner, Welk, Münzel and Gori.

Figures

Figure 1
Figure 1
Study protocol.
Figure 2
Figure 2
The impact of the three study medications on microvascular function. PORH (post-occlusion reactive hyperemia) was improved acutely after loading by prasugrel, however this effect was lost after percutaneous intervention.
Figure 3
Figure 3
Correlation between platelet activity and PORH.

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