Effect of Pre-Hospital Crushed Prasugrel Tablets in Patients with STEMI Planned for Primary Percutaneous Coronary Intervention: The Randomized COMPARE CRUSH Trial

• Published in: Circulation (New York, N.Y.) N.Y.), 2020-11
• Main Authors: Vlachojannis, Georgios J, Wilschut, Jeroen M, Vogel, Rosanne F, Lemmert, Miguel E, Delewi, Ronak, Diletti, Roberto, van der Waarden, Nancy W.P.L, Nuis, Rutger-Jan, Paradies, Valeria, Alexopoulos, Dimitrios, Zijlstra, Felix, Montalescot, Gilles, Angiolillo, Dominick J, Krucoff, Mitchell W, Van Mieghem, Nicolas M, Smits, Pieter C
• Format: Article
• Language: English
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.120.051532

BACKGROUND:Early treatment with a potent oral platelet P2Y12 inhibitor is recommended in patients presenting with ST-segment elevation myocardial infarction (STEMI) planned to undergo primary percutaneous coronary intervention (pPCI). The impact on coronary reperfusion of crushed P2Y12 inhibitor tablets, which lead to more prompt and potent platelet inhibition, is unknown. METHODS:We conducted a randomized controlled, multicenter trial in the Netherlands, enrolling STEMI patients planned to undergo pPCI. Patients were randomly allocated to receive in the ambulance, before transfer, a 60 mg loading dose (LD) of prasugrel either as crushed or integral tablets. The independent primary end points 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 end points were TIMI major and bleeding academic research consortium (BARC) ≥3 bleedings. Secondary end points included platelet reactivity and ischemic outcomes. RESULTS:A total of 727 patients were assigned to either crushed or integral tablets of prasugrel LD. The median time from study treatment to wire-crossing during pPCI was 57 [47 – 70] minutes. The primary end point TIMI 3 flow in the IRA pre-pPCI occurred in 31.0% in the crushed group vs. 32.7% in the integral group (OR 0.92 [95% CI 0.65 – 1.30], P=0.64). Complete ST-segment resolution one hour post-pPCI was present in 59.9% in the crushed group vs. 57.3% in the integral group (OR 1.11 [95% CI 0.78 – 1.58], P=0.55). Platelet reactivity at the beginning of pPCI, measured as P2Y12 reactivity unit, differed significantly between groups (crushed, 192 [132 – 245] vs. integral, 227 [184 – 254], P=