Tratamiento antiagregante en el Síndrome coronario agudo. Seguridad y eficacia del cruce entre antiagregantes

Abstract

Aims. Dual antiplatelet therapy (DAPT) is a cornerstone for the management of patients with acute coronary syndrome (ACS). However, the efficacy and safety of switching between P2Y12 ADP receptor inhibitors in patients with ACS remain unclear. We assessed the safety of switching between P2Y12 ADP receptor inhibitors in terms of major bleeding in patients with ACS. Methods. Observational, prospective, monocenter registry study. A total of 246 consecutive patients after admission by ACS in acute cardiac care unit were enrolled from 27 February 2015 to 31 May 2016. Cox proportional hazard regression modeling was used to determine clinical factors associated with mayor bleeding (BARC 3) or switching antiplatelet strategy over a year period. Results. Switching between P2Y12 ADP receptor inhibitors occurred in 122 patients (49.6%). The switching group patients were younger, better renal function, lower GRACE ischemic risk score, lower history of cardiac arrhythmia, more fibrinolytic use in the SCACEST and more pharmacoactive stent implantation. A lower rate of major cardiovascular event (MACE) was detected (10.7% [95% CI: 5.2-16.1] vs 20.2% [95% CI: 13.1-27.2]; p=0.039) in the switching group, at the expense mainly of mortality reduction (4.1% [95% CI: 1.3-9.3] vs 12.9% [95% CI: 7.0-18.8]; p=0.013). Predictors against switching were age (HR: 0.97; 95% CI: 0.95-0.98; p=0.00005) and the use of potent P2Y12 ADP receptor inhibitors. Bleeding occurred in 112 patients (45.5%) at follow-up. The incidence of major bleeding was 8.5%. Gastrointestinal bleeding was the most frequent major bleeding. No significant differences were observed in the crude rate of major bleeding (no switching group 10.5% [95% CI: 5.1-15.9] vs switching 6.6% [95% CI: 1.8-11.4]; p=0.270) or adjusted rate between treatment groups. The highest CRUSADE risk score (HR: 1.05; 95% CI: 1.03-1.08; p=0.0005) and anticoagulation at discharge (HR: 5.07; 95% CI: 1.11-23.14; p=0.010) they were risk predictors until major bleeding. Pretreatment was a protective predictor until the presentation of major bleeding (HR: 0.32; 95% CI: 0.13-0.83; p=0.019). Switching between antiplatelet will not be seen as a predictor of major bleeding. Conclusions. Switching between P2Y12 ADP receptor inhibitors in patients with ACS is not associated with an increased risk of major bleeding in the population analyzed. However, the highest CRUSADE risk score and anticoagulation at discharge were predictors of major bleeding and de pretreatment with P2Y12 ADP receptor inhibitors was a major bleeding protective factor in the population analyzed.