Topol called the Prasugrel results "incremental efficacy" and said the trial only suggests the drug should be used in a "narrow group of patients." Topol was the heart specialist invited to comment on the study.
"Overall, the number of cardiac events averted was larger than bleeding events caused by Prasugrel," said Harlan Krumholz, professor of medicine, epidemiology and public health at Yale University. "But the clinical decision can be improved by tailoring it to the patient's risk profile for cardiac events and bleeding."
Bhatt specifies in his editorial the subgroups of patients who received no clinical benefit from Prasugrel — specifically, patients older than 75, those who are underweight, those with cerebrovascular disease and those with a history of stroke. Moreover, because Prasugrel increases risk of heavy or even fatal bleeding, patients who are expected to receive major heart surgery, such as coronary artery bypass graft surgery, should not consider this potent drug thinner as a treatment option.
Because the trial was successful in determining subgroups of patients who would receive no clinical benefit from Prasugrel, many doctors and surgeons believe that if prescribed responsibly — that is, taking into account each patient's specific risk factors — Prasugrel has the potential to become a positive addition to the current standard of treatment for heart attack patients.
"If the protocol of the study is followed and the patient does not receive [Prasugrel] until the angiography is done, and … complex or higher risk anatomy is avoided, then the risk of needing emergency surgery and severe hemorrhage is very low and acceptable," said Nicholas Smedira, surgical director of the Kaufman Center for Heart Failure.
More importantly, many physicians stress the need for public education on the topic of which patients will and which will not benefit from the use of Prasugrel.
"If CABG [coronary artery bypass graft] is needed and you are on this drug, it will be a problem," said Thoralf Sundt, professor of cardiovascular surgery at the Mayo Clinic in Rochester, Minn. "It is important for the public to understand this as these drugs get pushed onto the masses with direct marketing."