Tailored Antiplatelet Therapy Versus Recommended Dose of Prasugrel (ANTARCTIC)

• Composite of Cardiovascular death, myocardial infarction, stroke, urgent revascularisation, stent thrombosis and bleedings according to the BARC definitions (type 2, 3 or 5) [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  Composite of Cardiovascular death, myocardial infarction, stroke, urgent revascularisation, stent thrombosis and bleedings according to the BARC definitions (type 2, 3 or 5) at 12 months
  
  

• Evaluation of the benefice of prasugrel adjustment on the composite ischemic endpoint of cardiovascular (CV) death, MI, definite stent thrombosis and Urgent revascularisation [ Time Frame: 12 months after randomization ] [ Designated as safety issue: No ]
  The key secondary objective is to evaluate the benefice of prasugrel adjustment on the composite ischemic endpoint of cardiovascular (CV) death, MI, definite stent thrombosis and Urgent revascularisation through 12 months of randomisation
  
  
• CV death, MI, stroke [ Time Frame: 12 months after randomization ] [ Designated as safety issue: No ]
  
• CV death, MI, stroke or Urgent Revascularization [ Time Frame: 12 months after randomization ] [ Designated as safety issue: No ]
  
• CV death: any death through at 12 months [ Time Frame: 12 months after randomization ] [ Designated as safety issue: No ]
  
• Any death or resuscitated cardiac death through at 12 months [ Time Frame: 12 months after randomization ] [ Designated as safety issue: No ]
  
• CV death or MI [ Time Frame: 12 months after randomization ] [ Designated as safety issue: No ]
  
• Definite stent thrombosis (ARC definition) [ Time Frame: 12 months after randomization ] [ Designated as safety issue: No ]
  
• All types of bleeding according to the BARC definitions 1, 2, 3, 4, 5 [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  
• BARC Bleeding of type 2, 3 or 5 [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  
• Bleeding TIMI major [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  
• GUSTO severe or moderate bleeding [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  
• STEEPLE bleeding definitions (major, minor or both) [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  
• ISTH bleeding definitions (major and clinically relevant non major) [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  
• Bleeding TIMI minor [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  
• Bleeding TIMI minimal [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  
• Bleeding TIMI major, minor and combination [ Time Frame: 12 months after randomization ] [ Designated as safety issue: Yes ]
  

Objective: To demonstrate the superiority of a strategy of platelet monitoring (Monitoring Arm) with down-adjustment of the dose of prasugrel in high responders and up-adjustment of the dose of prasugrel in low responders as compared to a more conventional strategy of a fixed dose of 5 mg to every patient without monitoring (Conventional Arm).Rationale: Prasugrel 10 mg is superior to clopidogrel in patients with acute coronary syndrome treated by percutaneous coronary intervention, reducing significantly the rates of ischemic events. Elderly patients appear to be at higher risk of bleeding events and pharmacokinetic data suggests that elderly patients are exposed to a higher concentration of the active metabolite of prasugrel. A reduced dose of 5 mg of prasugrel is therefore proposed to these patients to limit the risk of bleeding. On the other hand, the elderly have also a higher ischemic risk and higher levels of platelet aggregation under treatment than younger patients and may deserve stronger protection from antiplatelet therapy. Platelet function testing appears to be of particular interest in patients at high risk of both ischemic and bleeding events like the elderly. Too intense platelet inhibition may expose the elderly patients to an excessive bleeding risk. Too low platelet inhibition may expose them to recurrent cardiovascular ischemic events. The possibility of bedside monitoring of oral antiplatelet therapy offers the opportunity of tailoring prasugrel therapy in elderly patients to optimize their risk/benefit ratio. Such strategy has never been evaluated in a randomized and adequately powered study. Population: Acute coronary syndrome (STEMI and NSTEMI) treated by PCI-stent (bare metal stent or drug eluting stent) in patients aged 75 ≥ year. Methods: Monitoring with VerifyNow P2Y12, 2 weeks after initiation of 5 mg of maintenance dose of prasugrel, reduction of antiplatelet therapy if there is high on-treatment platelet inhibition (HPI) or increase in dosing if there is high on-treatment platelet reactivity (HPR). Patients will be monitored again 2 weeks later, only if they do not meet the Verifynow P2Y12 targets at the first assessment. Primary endpoint net clinical benefit at 12 months:Composite of Cardiovascular death, myocardial infarction, stroke, urgent revascularisation, stent thrombosis and bleedings according to the BARC definitions (type 2, 3 or 5) Centers: 50 French high volume PCI centers