Guided P2Y12 inhibitor selection after rapid CYP2C19 genotyping in patients undergoing percutaneous coronary intervention

CYP2C19

CYP2C19 loss-of-function alleles limiting clopidogrel bioactivation, with rapid genotyping at the time of intervention to guide P2Y12 inhibitor selection

This real-world study included 974 patients who underwent rapid CYP2C19 genotyping at the time of percutaneous coronary intervention. Clopidogrel was prescribed more often at discharge in non-carriers of a loss-of-function allele than in carriers (43% vs 31%). Among carriers who de-escalated to clopidogrel, median de-escalation time was 180 days. After stratification on loss-of-function status and time-varying Cox adjustment, major atherothrombotic events did not differ between clopidogrel and prasugrel or ticagrelor, in carriers (adjusted HR 0.87; 95% CI 0.36-2.10) or non-carriers (adjusted HR 1.26; 95% CI 0.67-2.36), with no difference in bleeding either.

Synthesis written by Geno'X. For the full original abstract, please refer to the source publication.

The useful finding is not the absence of outcome differences, which the sample size could not settle given very wide confidence intervals, but the description of practice: rapid genotyping shifts discharge prescribing without determining it, and de-escalation to clopidogrel occurs after a median of six months. The authors themselves call for cautious interpretation. This observational study usefully complements randomised trials of guided de-escalation, without being able to replace them.

Analysis by Dr Thibaut Benquey