Smoking and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients: a substudy from the randomized TROPICAL-ACS trial.

Orban, Martin; Trenk, Dietmar; Geisler, Tobias; Rieber, Johannes; Hadamitzky, Martin; Gross, Lisa; Orban, Mathias; Kupka, Danny; Baylacher, Monika; Müller, Susan; Huber, Kurt; Koltowski, Lukasz; Huczek, Zenon; Heyn, Jens; Jacobshagen, Claudius; Aradi, Dániel; Massberg, Steffen; Sibbing, Dirk; Hein, Ralph

doi:10.1093/ehjcvp/pvz084

journal article

Title:: Smoking and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients: a substudy from the randomized TROPICAL-ACS trial.
Document type:: Journal Article
Author(s):: Orban, Martin; Trenk, Dietmar; Geisler, Tobias; Rieber, Johannes; Hadamitzky, Martin; Gross, Lisa; Orban, Mathias; Kupka, Danny; Baylacher, Monika; Müller, Susan; Huber, Kurt; Koltowski, Lukasz; Huczek, Zenon; Heyn, Jens; Jacobshagen, Claudius; Aradi, Dániel; Massberg, Steffen; Sibbing, Dirk; Hein, Ralph
Abstract:: AIMS: Prior analyses disclosed variations in antiplatelet drug response and clinical outcomes between smokers and non-smokers, thus the safety and efficacy of any dual antiplatelet therapy (DAPT) de-escalation strategy may differ in relation to smoking status. Hence, we assessed the impact of smoking on clinical outcomes and adenosine diphosphate-induced platelet aggregation following guided de-escalation of DAPT in invasively managed acute coronary syndrome (ACS) patients. METHODS AND RESULTS: The multicentre TROPICAL-ACS trial randomized 2610 biomarker-positive ACS patients 1:1 to standard treatment with prasugrel for 12 months (control group) or a platelet function testing guided de-escalation of DAPT. Current smokers (n = 1182) showed comparable event rates between study groups [6.6% vs. 6.6%; hazard ratio (HR) 1.0, 95% confidence interval (CI) 0.64-1.56, P > 0.99]. In non-smokers (n = 1428), a guided DAPT de-escalation was associated with a lower 1-year incidence of the primary endpoint [cardiovascular death, myocardial infarction, stroke, or bleeding ≥ Grade 2 according to Bleeding Academic Research Consortium (BARC) criteria] compared with control group patients (7.9% vs. 11.0%; HR 0.71, 95% CI 0.50-0.99, P = 0.048). This reduction was mainly driven by a lower rate of BARC ≥ Grade 2 bleedings (5.2% vs. 7.7%; HR 0.68, 95% CI 0.45-1.03, P = 0.066). There was no significant interaction of smoking status with treatment effects of guided DAPT de-escalation (Pint = 0.23). Adenosine diphosphate-induced platelet aggregation values were higher in current smokers [median 28 U, interquartile range (IQR: 20-40)] vs. non-smoker [median 24 U (16-25), P < 0.0001] in the control group and in current smokers [median 42 U, IQR (27-68)] vs. non-smoker [median 37 U, IQR (25-55), P < 0.001] in the monitoring group. CONCLUSION: Guided DAPT de-escalation appears to be equally safe and effective in smokers and non-smokers. Regardless of smoking status and especially for those patients deemed unsuitable for 1 year of potent platelet inhibition this DAPT strategy might be used as an alternative antiplatelet treatment regimen.
Journal title abbreviation:: Eur Heart J Cardiovasc Pharmacother
Year:: 2020
Journal volume:: 6
Journal issue:: 6
Pages contribution:: 372-381
Fulltext / DOI:: doi:10.1093/ehjcvp/pvz084
Pubmed ID:: http://view.ncbi.nlm.nih.gov/pubmed/31855244
Print-ISSN:: 2055-6837
TUM Institution:: Institut für Radiologie und Nuklearmedizin
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