harmonizing optimal strategy for treatment of coronary artery diseases trial - comparison of reduction of prasugrel dose & polymer technology in acs patients (host reduce polytech rct trial)

Conditions: Acute Coronary Syndrome

Summary: * study objectives 1. to compare the safety and long-term efficacy of coronary stenting with biostable polymer drug-eluting stent (promus premiertm, xience alpine®, resolute onyx®) with biodegradable polymer drug-eluting stent (biomatrix®, biomatrix flex®, nobori®, ultimaster®, synergy ® and orsiro®) in patients with acute coronary syndrome 2. to compare the efficacy and safety of 5 mg prasugrel maintenance therapy compared with 10 mg prasugrel maintenance therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention * study design : prospective, open-label, 2-by-2 multifactorial, randomized, multicenter trial to test the following in chd patients 1. non-inferiority of biostable polymer drug-eluting stent (promus premiertm, xience alpine®, resolute onyx®) compared with biodegradable polymer drug-eluting stent (biomatrix®, biomatrix flex®, nobori®, ultimaster®, synergy ® and orsiro®) in terms of patient-oriented composite outcome 2. non-inferiority of 5 mg compared to 10 mg dose of prasugrel maintenance in terms of major adverse cardiovascular events

about 3400 patients derived from a population of korean patients with acute coronary syndrome receiving percutaneous coronary intervention will be enrolled in the present trial. all patients will receive a loading dose of aspirin (300 mg) and prasugrel (60 mg bolus) will be administered. sixty-mg-loading dose of prasugrel will be given regardless of pretreated antiplatelet agents (clopidogrel, ticagrelor, or cilostazol). however, in patients who already loaded with other antiplatelet agents (clopidigrel, ticagrelor, or cilostazol), reduced dose (30mg) or omission of prasugrel loading is acceptable. following angiography, patients with significant diameter stenosis \>50% of coronary artery or graft vessel by visual estimation that have documented myocardial ischemia or symptoms of angina, and have lesions that are eligible for coronary intervention without any exclusion criteria, will be randomized 1:1 to either receive either bs-des or bd-des group. at 1-month clinical follow-up, patients eligible for antiplatelet comparison will be additionally randomized 1:1 to either receive the reduce dose of prasugrel (5 mg daily) or conventional dose (10 mg daily). the exclusion criteria (age ≥75 years, body weight \<60 kg, or history of tia or stroke) is classified as observational cohort. post-pci, dual antiplatelet therapy is recommended for at least 1 year. follow-up data will be collected until 3-year after index procedure.

Eligibility criteria:
inclusion criteria: * subject must be ≥ 18 years * subject is able to verbally confirm understandings of risks, benefits and treatment alternatives of receiving pci and he/she or his/her legally authorized representative provides written informed consent prior to any study related procedure. * subject must have a culprit lesion in a native coronary artery with significant stenosis (\>50% by visual estimate) eligible for stent implantation * subject must have clinical diagnosis of acute coronary syndrome exclusion criteria: * following patients will be enrolled in stent comparison, but excluded from antiplatelet comparison. they will be classified as observational cohort. * subjects ≥75 years * body weight \<60 kg * history of tia or stroke * the patient has a known hypersensitivity or contraindication to any of the following medications: heparin, aspirin, clopidogrel, prasugrel, ticagrelor, biolimus, everolimus, contrast media (patients with documented sensitivity to contrast media which can be effectively premedicated with steroids and diphenhydramine \[e.g. rash\] may be enrolled. those with true anaphylaxis to prior contrast media, however, should not be enrolled.) * patients with active pathologic bleeding * gastrointestinal or genitourinary bleeding within the prior 3 months, or major surgery within 2 months. * systemic (intravenous) biolimus, or everolimus use within 12 months. * female of childbearing potential, unless a recent pregnancy test is negative, who possibly plan to become pregnant any time after enrollment into this study. * history of bleeding diathesis, known coagulopathy (including heparin-induced thrombocytopenia), or will refuse blood transfusions * non-cardiac co-morbid conditions are present with life expectancy \<1 year or that may result in protocol non-compliance (per site investigator's medical judgment).

Keywords: acute coronary syndrome drug eluting stent everolimus prasugrel