COMPARE CRUSH looked at the P2Y12 pre-treatment of STEMI patients undergoing primary PCI. The study randomized 727 patients (633 were evaluated in the modified intention to treat) to pre-hospital crushed versus uncrushed prasugrel tablets. The results showed that crushed tablets did not improve TIMI 3 flow in the IRA at first angiography (31% versus 32.7%) but TIMI 3 flow grades in both groups were higher than the expected rate of 17%, even after excluding patients who did not have a true STEMI.   ST-segment resolution at 1-hour post-PCI was similar in both groups. Platelet reactivity was lower in the crushed prasugrel arm, but this did not translate into lower stent thrombosis (trial was underpowered for clinical endpoints). Therefore, although crushing P2Y12A inhibitors (Prasugrel and Ticagrelor) prior to administration increases bioavailability and inhibits platelets faster, the clinical impact of is unknown (all trials were underpowered for clinical events.  However, to date, there has been no harm of crushing these drugs, so it makes sense to perform high risk PCI procedures with adequate antiplatelet drugs on board. 

All Editors: David A. Cox, MD, MSCAI, Allison G. Dupont, MD, FSCAI, Kirk N. Garratt, MD, MSc, MSCAI, Cindy L. Grines, MD, MSCAI, Andrew J. Klein, MD, FSCAI, and Jordan Safirstein, MD, FSCAI.