Platelet Function Monitoring Fails to Improve Outcomes in Elderly Stent Recipients

August 27, 2016

Platelet Function Monitoring Fails to Improve Outcomes in Elderly Stent Recipients

  1. Harlan M. Krumholz, MD, SM

Results of the ANTARCTIC trial suggest that using platelet function testing to adjust antiplatelet treatment confers no benefit, even in high-risk populations.

  1. Harlan M. Krumholz, MD, SM

Outcome trials have failed to demonstrate the utility of routine platelet function testing before or after stenting, and such testing carries a class III recommendation (is not recommended) in European and American guidelines. However, monitoring platelet function carries a class IIb recommendation (might be reasonable; level of evidence, C) in certain high-risk situations and has gained popularity among some clinicians, perhaps because selecting and titrating antiplatelet treatment based on a physiological parameter seems sensible. Now, in an industry-funded study, investigators have evaluated the use of platelet function monitoring to adjust antiplatelet treatment after stent placement for acute coronary syndrome in patients aged 75 years or older.

In a multicenter, open-label, blinded-endpoint trial, researchers at 35 French hospitals randomized 877 patients to receive platelet function monitoring or usual care. Both groups began with oral prasugrel, 5 mg daily. In the monitoring group, platelet inhibition was tested 14 days after randomization and was within target range in 42% of patients. Patients whose treatment was subsequently adjusted underwent platelet inhibition testing again 14 days later.

At 12 months, the rate of the primary composite endpoint (cardiovascular death, myocardial infarction, stroke, stent thrombosis, urgent revascularization, or Bleeding Academic Research Consortium–defined bleeding) was 28% in both groups (hazard ratio, 1.003; 95% confidence interval, 0.78–1.29). None of the endpoint's components differed significantly between the two groups.

Comment

In this study, investigators sought to optimize the use of platelet function monitoring in the care of older patients undergoing stenting for an acute coronary syndrome, but no benefit was detected. Either we do not know how best to use platelet function testing, the test used in this study (VerifyNow P2Y12) is ineffective in this setting, or the strategy itself simply does not work. Until clinical value can be shown, its use is hard to justify.

Editor Disclosures at Time of Publication

  • Disclosures for Harlan M. Krumholz, MD, SM at time of publication Consultant / Advisory board United Healthcare (Advisory Board); Element Science (Consultant) Equity ImageCor; Hugo PHR Grant / Research support Agency for Healthcare Research and Quality; Food and Drug Administration; National Heart, Lung, and Blood Institute; Robert Wood Johnson Foundation; Medtronic; Johnson & Johnson; Chinese National Center for Cardiovascular Disease; Centers for Medicare & Medicaid Services Editorial boards BMJ.com/US; American Journal of Managed Care; American Journal of Medicine; Archives of Medical Science; Critical Pathways in Cardiology; Current Cardiovascular Risk Reports; JACC: Cardiovascular Imaging; Circulation: Cardiovascular Quality and Outcomes; Circulation (Associate Editor)

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