Safety and efficacy of P2Y12 inhibitors in acute coronary syndromes patients with KDIGO stage IV-V renal disfunction not on dialysis: a subanalysis of the CORALYS registry

Background: The impact of the most potent P2Y12i ticagrelor and prasugrel after acute coronary syndrome in patients with chronic kidney disease (CKD) remains unclear. Most evidence on dual antiplatelet therapy (DAPT) comes from real-world study but is limited to glomerular filtration rate (GFR) under 60 ml/min. Methods: Consecutive patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) and severe CKD defined as GFR under 30 ml/min not on dialysis from the CORALYS registry were included. Incidence of Net Adverse Clinical Events (NACE) defined as major adverse cardiac events (cardiovascular death, myocardial infarction and unplanned revascularizations) in addition to major bleedings was our primary endpoint. Overall MACE and their single components, all bleedings, major bleedings and hospitalizations for heart failure were the secondary ones. Results: 257 patients with severe CKD not on dialysis and available data on antiplatelet regimen at discharge were included, 193 (75.1 %) were given clopidogrel while 64 (24.9 %) with ticagrelor or prasugrel. Our population was predominantly male (153, 59.5 %) with an average age 75.8 ± 10.9 years old. Over a median follow-up of 459 days, Ticagrelor and Prasugrel were associated to lower rates of NACE compared to Clopidogrel (39.9 % vs 25.0 %, p = 0.036). This was mainly driven by an excess of both CV mortality and myocardial infarction reported in the clopidogrel group. No difference was reported regarding overall bleeding events and major bleedings. At multivariate Cox regression analysis DAPT with Ticagrelor/Prasugrel resulted independently associated with a lower risk of NACE whereas left main involvement or multivessel coronary disease led to higher risk of NACE. Conclusions: In ACS patients treated with PCI with severe CKD ticagrelor and prasugrel were associated to lower risk of NACE, MACE, CV death and myocardial infarction compared to clopidogrel. No significative difference was reported in overall and major bleedings.