Tailored P2Y12 inhibitor treatment in patients undergoing non-urgent PCI—the POPular Risk Score study

  • Paul W. A. JanssenEmail author
  • Thomas O. Bergmeijer
  • Gert-Jan A. Vos
  • Johannes C. Kelder
  • Khalid Qaderdan
  • Thea C. Godschalk
  • Nicoline J. Breet
  • Vera H. M. Deneer
  • Christian M. Hackeng
  • Jurriën M. ten Berg



The POPular Risk Score was developed for the selective intensification of P2Y12 inhibitor treatment with prasugrel instead of clopidogrel in patients undergoing non-urgent percutaneous coronary intervention (PCI) with stent implantation. This score is based on platelet reactivity (VerifyNow P2Y12 assay), CYP2C19 genotyping, and clinical risk factors. Our aim was to determine if the use of this score in clinical practice is associated with a reduction in thrombotic events without increasing bleeding events.


In a single-center prospective cohort study, patients with a high risk score were treated with prasugrel and patients with a low risk score with clopidogrel. The risk score–guided cohort was compared with a historic cohort of clopidogrel-treated patients. The endpoint consisted of all-cause death, myocardial infarction, stroke, or stent thrombosis during 1 year of follow-up. TIMI major and minor bleeding events were also analyzed.


The guided cohort contained 1127 patients, 26.9% of whom were switched to prasugrel according to the POPular Risk Score. The historic cohort contained 893 patients. The incidence of the combined thrombotic endpoint was significantly lower in the guided cohort as compared with the historic cohort (8.4% versus 3.7%, p < 0.001). This strategy was safe with respect to bleeding (4.0% versus 1.3%, p < 0.001, for TIMI major or minor bleeding). Results were comparable after multivariate and propensity score matched and weighted analysis.


Selective intensification of P2Y12 inhibitor treatment after non-urgent PCI based on the POPular Risk Score is associated with a reduction in thrombotic events without an increase in bleeding events.


Platelet aggregation CYP2C19 Percutaneous coronary intervention P2Y12 inhibitor Clopidogrel Prasugrel 



The authors would like to thank all personnel of the St. Antonius Hospital and the referring hospitals involved in this project.

Authors’ contributions

PWAJ, TOB, GJAV, and JCK had full access to all the study data and took responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: PWAJ, TOB, JCK, NJB, VHMD, CMH, and JMB. Drafting of the manuscript: PWAJ, TOB, JCK, TCG, and KQ. Critical revision of the manuscript for important intellectual content: all authors. Acquisition, analysis, or interpretation of data: all authors.


This study was supported by the St. Antonius Innovation fund and a ZonMw TopZorg grant. ZonMw is a Dutch organization funded by the government promoting health care research and the implementation of study results in daily practice. The authors were solely responsible for the design and conduct of this study, all study analyses, and the drafting and editing of the paper and its final contents.

Compliance with ethical standards

The study was conducted according to the principles of the Declaration of Helsinki and received approval from the local human research ethics committee. Approval for this registry included a waiver of the need for written informed consent.

Conflict of interest

JMtB reports receiving advisory/consulting/speakers fees from AstraZeneca, Eli Lilly, Daiichi Sankyo, the Medicines Company, Accumetrics, Boehringer-Ingelheim, BMS, Pfizer, Bayer. All other authors have nothing to declare. The department of cardiology of the St. Antonius Hospital has received research grants from ZonMw and AstraZeneca.

Supplementary material

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Paul W. A. Janssen
    • 1
    • 2
    Email author
  • Thomas O. Bergmeijer
    • 1
    • 2
  • Gert-Jan A. Vos
    • 1
    • 2
  • Johannes C. Kelder
    • 1
    • 2
  • Khalid Qaderdan
    • 1
    • 2
  • Thea C. Godschalk
    • 1
    • 2
  • Nicoline J. Breet
    • 2
    • 3
  • Vera H. M. Deneer
    • 2
    • 4
  • Christian M. Hackeng
    • 2
    • 5
  • Jurriën M. ten Berg
    • 1
    • 2
  1. 1.Department of CardiologySt Antonius HospitalNieuwegeinThe Netherlands
  2. 2.St Antonius Centre for Platelet Function ResearchSt Antonius HospitalNieuwegeinThe Netherlands
  3. 3.Department of CardiologyGelre ziekenhuizenApeldoornThe Netherlands
  4. 4.Department of Clinical PharmacyUniversity Medical Centre UtrechtUtrechtThe Netherlands
  5. 5.Department of Clinical ChemistrySt Antonius HospitalNieuwegeinThe Netherlands

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