興梠 貴英

BACKGROUND: There are few data verifying the utility of the CHADS-P2A2RC score in comparison with the CHADS2 score for estimating net adverse clinical events (NACE) in chronic coronary syndrome (CCS) patients without atrial fibrillation (AF) in real-world settings. METHODS: We performed analysis for a total of 3985 CCS patients without AF who underwent percutaneous coronary intervention (PCI) between April 2013 and March 2019 for whom information was obtained from the CLIDAS (Clinical Deep Data Accumulation System)-PCI database. The primary endpoint was NACE defined as the composite of 3-point major adverse cardiovascular events (3P-MACE) (cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke) and GUSTO moderate/severe bleeding events. RESULTS: Kaplan-Meier analysis showed that both the CHADS-P2A2RC and CHADS2 scores stratified the risks. The incidences of NACE were stratified well by the very-high-risk category, which was uniquely defined as a CHADS-P2A2RC score of ≥6 (hazard ratio: 2.38, 95 % CI = 1.91-2.97, p-value <0.001). The area under the curve (AUC) in estimating NACE within 3 years was higher when the CHADS-P2A2RC score was used than when the CHADS2 score was used (0.67 vs. 0.62, p = 0.003). This was mainly due to the accuracy in estimating bleeding events (0.66 vs. 0.60, p = 0.006). CONCLUSIONS: The accuracy in estimating NACE after PCI for CCS patients without AF was higher when the CHADS-P2A2RC score was used than when the CHADS2 score was used, mainly due to the accuracy in predicting bleeding risk. Higher incidences of endpoints were well-stratified by a very-high-risk category defined as a CHADS-P2A2RC score of ≥6.

BACKGROUND: Dual antiplatelet drug administration is recommended after percutaneous coronary intervention (PCI) stent placement. Although prasugrel, a newer P2Y12 inhibitor, reportedly suppresses cardiovascular events more effectively than the traditional agent clopidogrel, its preventive effects on cerebrovascular disorders remain a topic of ongoing debate. This study aimed to examine the cerebrovascular efficacy and safety of post-PCI prasugrel and clopidogrel using extensive real-world data in Japan. METHODS: Using the CLIDAS (Clinical Deep Data Accumulation System) database, 7412 post-PCI patients who received dual antiplatelet therapy between April 2013 and March 2019 were identified. The primary end point was defined as the incidence of any stroke, while secondary end points included individual ischemic and hemorrhagic cerebrovascular events. The incidence of cerebrovascular events was compared between the prasugrel (2.5–3.75 mg daily; n=2219) and clopidogrel (75 mg daily; n=5193) groups using propensity-score inverse probability of treatment weighting and Fine and Gray models to account for competing risks. RESULTS: Within 1 year after PCI, the prasugrel group had a significantly lower incidence of cerebrovascular events (subdistribution hazard ratio, 0.46 [95% CI, 0.24–0.91]; P =0.027) than the clopidogrel group. The subgroup analyses did not show significant differences in the incidence of ischemic (subdistribution hazard ratio, 0.54 [95% CI, 0.25–1.14]; P =0.11) and hemorrhagic cerebrovascular events (subdistribution hazard ratio, 0.30 [95% CI, 0.084–1.10]; P =0.070) between the use of prasugrel and clopidogrel. One-year health care costs between patients treated with prasugrel and those treated with clopidogrel showed no significant differences. CONCLUSIONS: Our data suggest that post-PCI prasugrel use was associated with lower cerebrovascular events compared with the use of clopidogrel in combination with aspirin. Further research is necessary to substantiate the potential of prasugrel in lowering cerebrovascular risks after post-PCI while upholding a satisfactory safety profile.