Potent P2Y₁₂ inhibitors in patients with acute myocardial infarction and cardiogenic shock

Background: Although potent P2Y₁₂ inhibitors, such as ticagrelor and prasugrel, are standard treatment in patients with acute myocardial infarction (AMI), evidence for their efficacy and safety compared with clopidogrel is limited in patients with AMI complicated by cardiogenic shock. Methods: Among 28,949 patients from the nationwide pooled registry of KAMIR-NIH and KAMIR-V, a total of 1482 patients (5.1%) with AMI and cardiogenic shock who underwent percutaneous coronary intervention of the culprit vessel were selected. Primary outcome was major adverse cardiovascular event (MACE, a composite of cardiac death, MI, repeat revascularization and definite stent thrombosis) and major secondary outcome was Bleeding Academic Research Consortium (BARC) type 2 or greater bleeding at 2 years. Results: Among the study population, 537 patients (36.2%) received potent P2Y₁₂ inhibitors and 945 patients (63.8%) received clopidogrel after index procedure. The risk of MACE was significantly lower in the potent P2Y₁₂ inhibitors group than in the clopidogrel group (16.6% versus 24.7%; adjusted hazard ratio [HR], 0.76 [95% CI 0.59–0.99]; P = 0.046). Regarding BARC type 2 or greater bleeding, there was no significant difference between the potent P2Y₁₂ inhibitors group and the clopidogrel group (12.5% versus 10.7%; adjusted HR, 1.36 [95% CI 0.98–1.88]; P = 0.064). Significant interaction was observed in patients aged ≥ 75 years (interaction P = 0.021) or venoarterial extracorporeal membrane oxygenator (VA-ECMO) use (interaction P = 0.015) for significantly increased risk of BARC type 2 or greater bleeding following the use of potent P2Y₁₂ inhibitors. Conclusions: In patients with AMI complicated by cardiogenic shock, the use of potent P2Y₁₂ inhibitors was associated with a lower risk of MACE compared with clopidogrel, without an increased risk of BARC type 2 or greater bleeding. The current data supports the use of potent P2Y₁₂ inhibitors in patients with AMI and cardiogenic shock, except in patients aged ≥ 75 years or receiving VA-ECMO support.