Coronary interventions

Diabetes and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients undergoing percutaneous coronary intervention: a pre-specified analysis from the randomised TROPICAL-ACS trial

EuroIntervention 2019;15:e513-e521. DOI: 10.4244/EIJ-D-18-01077

Ralph Hein
Ralph Hein1,2, MD; Lisa Gross1,2, MD; Dániel Aradi3, MD; Johannes Rieber4, MD; Martin Hadamitzky5, MD; Béla Merkely6, MD; Zenon Huczek7, MD; Hüseyin Ince8,9, MD; Astrid Hummel10, MD; Monika Baylacher1, MD; Steffen Massberg1,2, MD; Dietmar Trenk11, MD; Dirk Sibbing1,2, MD
1. Ludwig-Maximilians University, Department of Cardiology, Munich, Germany; 2. DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany; 3. Semmelweis University, Heart Centre Balatonfüred and Heart and Vascular Centre, Budapest, Hungary; 4. Klinikum Bogenhausen, Munich, Germany; 5. German Heart Center of Munich, Department of Radiology, Munich, Germany; 6. Semmelweis University, Heart and Vascular Centre, Budapest, Hungary; 7. Medical University of Warsaw, 1st Department of Cardiology, Warsaw, Poland; 8. Vivantes Klinikum Am Urban and im Friedrichshain, Department of Cardiology, Berlin, Germany; 9. Clinic for Internal Medicine, University of Rostock, Rostock, Germany; 10. Ernst-Moritz-Arndt University, Division for Internal Medicine, Greifswald, Germany; 11. University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany

Aims: A guided de-escalation of P2Y12 inhibitor treatment is considered an alternative treatment strategy in ACS patients undergoing PCI. However, the safety and efficacy of this strategy may differ in diabetic vs non-diabetic patients. The aim of this study was to compare the outcomes of platelet function testing (PFT)-guided de-escalation of dual antiplatelet therapy (DAPT) in ACS patients with and without diabetes mellitus.

Methods and results: The TROPICAL-ACS trial randomised 2,610 biomarker-positive ACS patients 1:1 to either standard treatment with prasugrel for 12 months (control group) or PFT-guided DAPT de-escalation. The association and interaction of diabetes on clinical endpoints across treatment groups and on platelet reactivity was investigated. In diabetic patients (n=527, 20.2%), the overall event rates were high and the one-year incidence of the primary endpoint (cardiovascular death, myocardial infarction, stroke or bleeding ≥grade 2) did not differ between guided de-escalation and control group patients (12.5% vs 10.8%; HR 1.17, 95% CI: 0.71–1.93, p=0.55). In non-diabetic patients (n=2,083, 79.8%), the one-year incidence of the primary endpoint was lower in the guided de-escalation vs control group (6.1% vs 8.5%; HR 0.71, 95% CI: 0.52–0.99, p=0.04, pint=0.10). Diabetic patients showed higher platelet reactivity levels in both control (=on prasugrel, p=0.01) and guided de-escalation group (=on clopidogrel, p=0.005) patients.

Conclusions: Although diabetic status did not significantly interfere with the treatment effects of guided DAPT de-escalation, our results suggest that this approach might be safe and effective in non-diabetic patients. Further investigation is definitely warranted in diabetic patients.

Sign in to read and download the full article

Forgot your password?

No account yet?
Sign up for free!

Create my pcr account

Join us for free and access thousands of articles from EuroIntervention, as well as presentations, videos, cases from PCRonline.com

acs/nste-acsadjunctive pharmacotherapybleedingdiabetesstemi
Coronary interventionsSTEMINSTEMIStents and scaffolds
Read next article
Standard versus ultrasound-guided radial and femoral access in coronary angiography and intervention (SURF): a randomised controlled trial

Latest news