Combined therapy with new P2Y12 receptor antagonists (prasugrel and ticagrelor) and bivalirudin in patients with acute coronary syndromes undergoing percutaneous coronary intervention

Background: For patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) current guidelines recommend antithrombotic therapy with new P2Y12 receptor antagonists (prasugrel and ticagrelor) as well as bivalirudin. Currently, there is limited long term experience with the combination of these 2 therapeutic options. Methods: Between May 2010 and November 2011, we identified 359 consecutive patients with ACS undergoing PCI, who were preloaded with either prasugrel or ticagrelor and received bivalirudin during PCI. Patients were preloaded as soon as possible before coronary angiography and PCI. The loading dose for prasugrel was 60 mg and for ticagrelor 180 mg. Immediately before PCI patients were treated with bivalirudin loading dose and with infusion during the PCI. Post PCI dual antiplatelet therapy was continued for 12 months independent of type of implanted stent. The 1 year incidences of death from any cause, the composite of death and myocardial infarction (MI) and of target vessel revascularisation (TVR) were analyzed. Results: One year follow-up was complete in all patients. Patients were 65 + 12 years old (patients with ticagrelor were in average 11 years older), 22% of patients were diabetic. STEMI patients were more frequent (70.8%) than NSTEMI patients (29.2%). With prasugrel were treated 87.0% of STEMI patients and with ticagrelor 71.4% of NSTEMI patients. Bail-out GP IIbIIIa –inhibitors were needed in 8.3%. The 1 year incidence of TVR was 16.1% in the prasugrel group and 13.9% in the ticagrelor group, those of death and MI 7.3% and 10.6% and those of death 6.5% and 8.6%, respectively. There was no case of subacute stent thrombosis. TIMI major bleeding occurred in 0.8% and only 1.1% of the patients needed blood transfusion. There were no significant differences between ticagrelor and prasugrel in any of the event rates. Conclusions: In patients with ACS undergoing PCI the combination of new generation P2Y12-selective inhibitors (prasugrel or ticagrelor) and bivalirudin is associated with low rates of severe bleeding complications and similar clinical outcome during 1 year follow-up between in the prasugrel and ticagrelor treatment group.