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Almendro-Delia M, Padilla-Rodríguez G, Hernández-Meneses B, Blanco-Ponce E, Arboleda-Sánchez JA, Rodríguez-Yáñez JC, Soto-Blanco JM, Fernández-García I, Castillo-Caballero JM, García-Rubira JC, Hidalgo-Urbano R. Nonadherence to ticagrelor versus clopidogrel and clinical outcomes in patients with ACS. Results from the CREA-ARIAM registry. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:113-124. [PMID: 37573968 DOI: 10.1016/j.rec.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/16/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES Prior studies have not determined whether the effect of dual antiplatelet therapy (DAPT) cessation on the subsequent risk of major adverse cardiac events (MACE) varies by the choice of P2Y12-inhibitor after acute coronary syndrome (ACS). METHODS We performed a prespecified subanalysis of a multicenter, prospective registry of ACS patients discharged on ticagrelor or clopidogrel between 2015 and2019. Nonadherence to DAPT was categorized as physician-guided discontinuation and disruption due to adverse effects, nonadherence, or bleeding. The association between DAPT cessation and 1-year MACE was analyzed using multivariate time-updated Cox models with inverse probability of censoring weighted estimators. RESULTS Out of 2180 patients, 174 (8.3%) prematurely discontinued DAPT (physician-guided, n=126; disruption, n=48). Nonadherent patients were older and had more comorbidities than those on DAPT. Compared with physician-guided discontinuation, disruption occurred earlier after discharge and was more frequent with ticagrelor than with clopidogrel. In time-varying analysis, DAPT cessation was associated with an increased risk of MACE (adjusted HR, 1.32, 95%CI, 1.10-1.76), largely driven by disruption (adjusted HR, 1.47, 95%CI, 1.22-1.73). There was an exponential increase in MACE risk after DAPT cessation within 90 days after ACS, especially after disruption of ticagrelor compared with clopidogrel (Pinteraction<.001). After adjustment for DAPT duration, this interaction was not statistically significant on the additive scale (relative excess risk due to interaction 0.12, 95%CI,-0.99-1.24). CONCLUSIONS In this all-comers registry, 1 in 12 patients prematurely discontinued DAPT within 1 year after ACS. Compared with physician-recommended discontinuation, disruption resulted in a significantly higher risk of MACE. After adjustment for DAPT duration, this association was not moderated by the choice of P2Y12-inhibitor. Clinical trial registered at ClinicalTrials.gov (Identifier: NCT02500290).
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Affiliation(s)
- Manuel Almendro-Delia
- Unidad de Agudos Cardiovascular, Hospital Universitario Virgen Macarena, Seville, Spain.
| | | | | | - Emilia Blanco-Ponce
- Servicio de Cardiología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | | | | | | | | | | | - Juan C García-Rubira
- Unidad de Agudos Cardiovascular, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Rafael Hidalgo-Urbano
- Unidad de Agudos Cardiovascular, Hospital Universitario Virgen Macarena, Seville, Spain
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Li Y, Zhao R, Yu P, Xu Y, Zhang Q, Han Y. The Increased Ischemic Risk During the Early Period After Clopidogrel Noncompliance in Patients with Acute Coronary Syndrome: A Meta-Analysis. Clin Appl Thromb Hemost 2023; 29:10760296231196477. [PMID: 37644847 PMCID: PMC10469223 DOI: 10.1177/10760296231196477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/03/2023] [Indexed: 08/31/2023] Open
Abstract
Although dual antiplatelet therapy for secondary prevention in acute coronary syndrome (ACS) is highly recommended by current guidelines, P2Y12 inhibitor non-adherence often occurs and devastates prognosis. To evaluate whether the ischemic risk during the early period of clopidogrel noncompliance was increased among ACS patients, a comprehensive search of PubMed, Embase, and Web of Science was conducted to identify studies reporting early ischemic risk after clopidogrel noncompliance in ACS patients. The primary endpoint was a composite of death or myocardial infarction (MI). Effect sizes were synthesized in patients with or without revascularization. A total of 7 observational studies focusing on clopidogrel noncompliance were included in this meta-analysis, whereas no studies involving ticagrelor or prasugrel were retrieved. A significantly increased risk of death or MI 0 to 90 days after clopidogrel noncompliance was found compared with that during 90 to 180 or 90 to 360 days regardless of revascularization (incidence rate ratio [IRR]: 2.01, 95% confidence interval (CI): 1.62-2.49, P < .001, I2 = 9%) or not (IRR: 1.61, 95% CI: 1.05-2.48, P < .001, I2 = 74%). Patients undergoing percutaneous coronary intervention had a higher risk of death or MI 0 to 90 days after clopidogrel noncompliance compared with 90-180 or 90-360 days irrespective of drug-eluting stent or bare metal stent implantation (P < .05 for both). The early ischemic risk after clopidogrel noncompliance is significantly higher than the late risk in ACS patients. Antiplatelet noncompliance remains a serious concern.
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Affiliation(s)
- Yushan Li
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Ruting Zhao
- Department of Internal Medicine, Chinese PLA No. 31694 Army Health Company, Benxi, China
| | - Peng Yu
- Department of Internal Medicine, Chinese PLA No. 65529 Army Health Company, Liaoyang, China
| | - Yan Xu
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Quanyu Zhang
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
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Pettersen TR, Schjøtt J, Allore HG, Bendz B, Borregaard B, Fridlund B, Larsen AI, Nordrehaug JE, Rotevatn S, Wentzel-Larsen T, Norekvål TM. Perceptions of generic medicines and medication adherence after percutaneous coronary intervention: a prospective multicentre cohort study. BMJ Open 2022; 12:e061689. [PMID: 36127123 PMCID: PMC9490600 DOI: 10.1136/bmjopen-2022-061689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To determine patient perceptions of generic medicines 2 and 6 months after percutaneous coronary intervention (PCI), and to determine whether these perceptions moderate medication adherence. DESIGN Prospective multicentre cohort study with repeated measures of perceptions of generic medicines and medication adherence. SETTING The CONCARDPCI study conducted at seven large referral PCI centres in Norway and Denmark between June 2017 and May 2020. PARTICIPANTS A total of 3417 adults (78% men), using both generic and brand name medicines, with a mean age of 66 years (SD 11) who underwent PCI were followed up 2 and 6 months after discharge from hospital. MAIN OUTCOME MEASURES Perceptions of generic medicines were the main outcome. The secondary outcome was medication adherence. RESULTS Perceptions of generic medicines were significantly more negative at 2 than at 6 months (1.10, 95% CI 0.41 to 1.79, p=0.002). Female sex (-4.21, 95% CI -6.75 to -1.71, p=0.001), older age (-0.12, 95% CI -0.23 to -0.02, p=0.020), lower education level (overall p<0.001), ethnicity (overall p=0.002), Norwegian nationality (10.27, 95% CI 8.19 to 12.40, p<0.001) and reduced self-reported health status (0.19, 95% CI 0.09 to 0.41, p=0.003) were significantly associated with negative perceptions of generic medicines. There was no evidence to suggest that perceptions of generic medicines moderate the association between sociodemographic and clinical variables and medication adherence (p≥0.077 for all covariates). Moreover, self-reported medication adherence was high, with 99% scoring at or above the Medication Adherence Report Scale midpoint at both time points. There were no substantial correlations between negative perceptions of generic medicines and medication non-adherence at 2 months (r=0.041, 95% CI 0.002 to 0.081, p=0.037) or 6 months (r=0.038, 95% CI -0.005 to 0.081, p=0.057). CONCLUSIONS Mistrust and uncertainty about the safety and efficacy of generic medicines remains in a sizeable proportion of patients after PCI. This applies especially to those of lower socioeconomic status, older age, female sex, immigrants and those with poorer mental health. However, this study demonstrated a shift towards more positive perceptions of generic medicines in the longer term.
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Affiliation(s)
- Trond Røed Pettersen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
| | - Jan Schjøtt
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Heather G Allore
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo Faculty of Medicine, Oslo, Oslo, Norway
| | - Britt Borregaard
- Department of Cardiothoracic and Vascular Surgery, Odense Universitetshospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bengt Fridlund
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Kalmar, Sweden
| | - Alf Inge Larsen
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Jan Erik Nordrehaug
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
| | - Svein Rotevatn
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Tore Wentzel-Larsen
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
- Centre for Child and Adolescent Mental Health Eastern and Southern Norway, Oslo, Norway
| | - Tone Merete Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
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Tavenier AH, Mehran R, Chiarito M, Cao D, Pivato CA, Nicolas J, Beerkens F, Nardin M, Sartori S, Baber U, Angiolillo DJ, Capodanno D, Valgimigli M, Hermanides RS, van 't Hof AWJ, Ten Berg JM, Chang K, Kini AS, Sharma SK, Dangas G. Guided and unguided de-escalation from potent P2Y12 inhibitors among patients with ACS: a meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:492-502. [PMID: 34459481 DOI: 10.1093/ehjcvp/pvab068] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/08/2021] [Accepted: 08/26/2021] [Indexed: 11/14/2022]
Abstract
AIM Optimal dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) intends to balance ischemic and bleeding risks. Various DAPT de-escalation strategies, defined as switching from a full-dose potent to a reduced dose or less potent P2Y12 inhibitor, have been evaluated in several ACS-PCI trials. We aimed to compare DAPT de-escalation to standard DAPT with full dose potent P2Y12 inhibitors in ACS patients who underwent PCI. METHODS & RESULTS PubMed, Google Scholar and Cochrane Central Register of Controlled Trials were searched for eligible randomised controlled trials. Aspirin monotherapy trials were excluded. Five randomised trials (n = 10,779 patients) that assigned DAPT de-escalation (genetically guided to clopidogrel n = 1,242; platelet function guided to clopidogrel n = 1,304; unguided to clopidogrel n = 1,672; unguided to lower dose n = 1,170) versus standard DAPT (control group n = 5,391) were included in this analysis. DAPT de-escalation was associated with a significant reduction in Bleeding Academic Research Consortium ≥ 2 bleeding (HR 0.57, 95% CI 0.42-0.78; I2 = 77%) as well as major adverse cardiac events, represented in most trials by the composite of cardiovascular mortality, myocardial infarction, stent thrombosis and stroke (HR 0.77, 95% CI 0.62-0.96; I2 = 0%). Notwithstanding the limited power, consistency was noted across various de-escalation strategies. CONCLUSION De-escalation of DAPT after PCI for ACS, both unguided and guided by genetic or platelet function testing, was associated with lower rates of clinically relevant bleeding and ischemic events as compared to standard DAPT with potent P2Y12 inhibitors based on five open-label RCTs reviewed.
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Affiliation(s)
- Anne H Tavenier
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Isala Heart Center, Zwolle, the Netherlands
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mauro Chiarito
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carlo A Pivato
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy.,Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | - Johny Nicolas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Frans Beerkens
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matteo Nardin
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Sartori
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Baber
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Marco Valgimigli
- Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Arnoud W J van 't Hof
- Isala Heart Center, Zwolle, the Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Jur M Ten Berg
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,St Antonius Hospital, Nieuwegein, the Netherlands
| | - Kiyuk Chang
- Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Annapoorna S Kini
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samin K Sharma
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George Dangas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Olufade T, Atreja N, Bhalla N, Venditto J, Bhandary D, Chafekar K, Cobden D, Khan ND. Hospitalization for Myocardial Infarction with Ticagrelor or Clopidogrel in Patients with Acute Coronary Syndrome: An On-Treatment Comparative Effectiveness Analysis. Cardiol Ther 2021; 10:515-529. [PMID: 34389941 PMCID: PMC8555031 DOI: 10.1007/s40119-021-00236-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 07/27/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Prescribing patterns and suboptimal adherence present methodological challenges for real-world head-to-head comparisons of ticagrelor and clopidogrel in intent-to-treat studies. The aim of this study was to compare ticagrelor and clopidogrel in an on-treatment population. METHODS This retrospective cohort study used the Optum™ Clinformatics™ database to identify patients with acute coronary syndrome (ACS) discharged on ticagrelor or clopidogrel between January 1, 2012 and September 30, 2019. The primary end point was hospitalization for myocardial infarction (MI); the secondary end point was hospitalization for major bleeding. The ticagrelor and clopidogrel cohorts were balanced by propensity score matching (PSM) 1:3 for demographic and clinical characteristics. Outcomes were ascertained from day 31 until day 365 or end of follow-up. RESULTS Of 339,387 patients with ACS, 14,110 ticagrelor- and 57,482 clopidogrel-treated patients met the study criteria. After PSM, 13,373 ticagrelor- and 29,656 clopidogrel-treated patients provided 4945 and 13,895 patient-years of data, respectively, for the primary end point. Hospitalization for MI was significantly lower in the ticagrelor compared to the clopidogrel cohort (2.22 vs. 3.52 per 100 patient-years; 36.8% relative risk reduction [RRR]; P < 0.0001). Hospitalization for major bleeding was similar in the ticagrelor and clopidogrel cohorts (2.04 vs. 2.06 per 100 patient-years; 1.1% RRR, P = 0.9214). CONCLUSIONS In this real-world on-treatment analysis, hospitalization for MI was significantly lower with ticagrelor compared to clopidogrel, with similar rates of hospitalization for major bleeding. Study findings underscore the importance of being on the appropriate guideline-recommended therapy and support the use of ticagrelor over clopidogrel.
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Affiliation(s)
- Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA
| | - Robert A. Harrington
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA
- Department of Medicine, Stanford University, Stanford, CA
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The effect of de-escalation of P2Y12 receptor inhibitor therapy after acute myocardial infarction in patients undergoing percutaneous coronary intervention: A nationwide cohort study. PLoS One 2021; 16:e0246029. [PMID: 33493236 PMCID: PMC7833092 DOI: 10.1371/journal.pone.0246029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 01/12/2021] [Indexed: 01/31/2023] Open
Abstract
To examine the effect of de-escalation of P2Y12 inhibitor in dual antiplatelet therapy (DAPT) on major adverse cardiovascular events (MACE) and bleeding complications after acute myocardial infarction (AMI) in Taiwanese patients undergoing percutaneous coronary intervention (PCI). Patients who had received PCI during hospitalization for AMI (between 2013 and 2016) and were initially treated with aspirin and ticagrelor and without adverse events after 3 months of treatment were retrospectively evaluated. In total, 1,901 and 8,199 patients were identified as “de-escalated DAPT” (switched to aspirin and clopidogrel) and “unchanged DAPT” (continued on aspirin and ticagrelor) cohorts, respectively. With a mean follow-up of 8 months, the incidence rates (per 100 person-year) of death, AMI readmission and MACE were 2.89, 3.68, and 4.91 in the de-escalated cohort and 2.42, 3.28, and 4.72 in the unchanged cohort, respectively, based on an inverse probability of treatment weighted approach that adjusting for baseline characteristics of the patients. Multivariate Cox regression analyses showed the two groups had no significant differences in the hazard risk of death, AMI admission, and MACE. Additionally, there was no observed difference in the risk of bleeding, including major or clinically relevant non-major bleeding. The real-world data revealed that de-escalation of P2Y12 inhibitor in DAPT was not associated with a higher risk of death or AMI readmission in Taiwanese patients with AMI undergoing successful PCI.
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Pietrzykowski Ł, Kasprzak M, Michalski P, Kosobucka A, Fabiszak T, Kubica A. Therapy Discontinuation after Myocardial Infarction. J Clin Med 2020; 9:jcm9124109. [PMID: 33352811 PMCID: PMC7766090 DOI: 10.3390/jcm9124109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 01/08/2023] Open
Abstract
The discontinuation of recommended therapy after myocardial infarction predisposes patients to serious thrombotic complications. The aim of this study was a comprehensive analysis of permanent as well as short- and long-term discontinuation of pharmacotherapy, taking into consideration the basic groups of medications and nonadherence determinants in a one-year follow-up in post-myocardial infarction (MI) patients. Material and methods: The study was a single center cohort clinical trial with a one-year follow-up including 225 patients (73.3% men, 26.7% women) aged 62.9 ± 11.9 years. In eight cases (3.6%), the follow-up duration was less than one year due to premature death. The following factors were analyzed: lack of post-discharge therapy initiation; short-term therapy discontinuation (<30 days); long-term therapy discontinuation (≥30 days); and permanent cessation of therapy. The analysis of therapy discontinuation was performed based on prescription filling data. Results: Occupational activity (Odds Ratio (OR) 5.15; 95% Confidence interval (CI) 1.42–18.65; p = 0.013) and prior MI (OR 5.02; 95% CI 1.45–16.89; p = 0.009) were found to be independent predictors of a lack of post-discharge therapy initiation with P2Y12 receptor inhibitors. We found no independent predictors of lack of post-discharge therapy initiation with other medications, whether analyzed separately or together. Age above 65 years (Hazard Ratio (HR)—1.59; 95% CI 1.15–2.19; p = 0.0049) and prior revascularization (HR—1.44; 95% CI 1.04–2.19; p = 0.0273) were identified as independent predictors of therapy discontinuation. Multilogistic regression analysis showed no independent predictors of the cessation of any of the medications as well as the permanent or temporary simultaneous discontinuation of all medications. Conclusions: The vast majority of post-MI patients discontinue, either temporarily or permanently, one of the essential medications within one year following myocardial infarction. The most likely medication class to be discontinued are statins. Older age and prior cardiac revascularization are independent determinants of therapy discontinuation.
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Affiliation(s)
- Łukasz Pietrzykowski
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (P.M.); (A.K.); (A.K.)
- Correspondence: ; Tel.: +48-52-585-58-35
| | - Michał Kasprzak
- Department of Cardiology, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (M.K.); (T.F.)
| | - Piotr Michalski
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (P.M.); (A.K.); (A.K.)
| | - Agata Kosobucka
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (P.M.); (A.K.); (A.K.)
| | - Tomasz Fabiszak
- Department of Cardiology, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (M.K.); (T.F.)
| | - Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (P.M.); (A.K.); (A.K.)
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Morita F, Wajngarten M, Katz M, Fernandes-Silva MM, Caixeta A, Franken M, Lemos PA, Pesaro AE. Short- and Midterm Adherence to Platelet P2Y12 Receptor Inhibitors After Percutaneous Coronary Intervention With Drug-Eluting Stents. J Cardiovasc Pharmacol Ther 2020; 25:466-471. [PMID: 32419491 DOI: 10.1177/1074248420926667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION/OBJECTIVES In patients who have undergone recent percutaneous coronary intervention (PCI), poor adhesion to antiplatelet agents may increase the risk of stent thrombosis and death. We aimed to investigate the adherence to different P2Y12 receptor inhibitors after PCI with drug-eluting stent in stable and unstable patients and to evaluate the factors associated with low adherence. METHOD In a prospective study conducted between 2014 and 2018, the 8-item Morisky scale was applied at 30 days and 6 months post-PCI to measure P2Y12 receptor inhibitors adherence. Also, we describe the characteristics of patients using different platelet receptor P2Y12 inhibitors. Regression models were used to identify predictors of poor adherence. RESULTS A total of 214 patients were included (65 ± 12 years, 81% man, 61% acute coronary syndromes). Patients in the clopidogrel group were older than those in the prasugrel (68 ± 12 vs 59 ± 11 years, P < .01, respectively) or ticagrelor group (68 ± 12 vs 62 ± 12 years, P < .01). Patients with low/moderate adherence at 30 days and 6 months represented, respectively, 19.8% and 27.5% of our sample. Current smokers and preexisting cardiovascular disease at presentation were associated with lower adherence at 30 days. CONCLUSIONS We found substantial rates of moderate and low adherence to P2Y12 receptor inhibitors early after PCI. Current smokers and preexisting cardiovascular disease at presentation were associated with a lower likelihood of adherence. These results highlight the need of monitoring adherence to medical treatment after PCI.
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Affiliation(s)
- Fernando Morita
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Mauricio Wajngarten
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcelo Katz
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Adriano Caixeta
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcelo Franken
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Pedro A Lemos
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Antonio E Pesaro
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Winter MP, von Lewinski D, Wallner M, Prüller F, Kolesnik E, Hengstenberg C, Siller-Matula JM. Incidence, predictors, and prognosis of premature discontinuation or switch of prasugrel or ticagrelor: the ATLANTIS - SWITCH study. Sci Rep 2019; 9:8194. [PMID: 31160687 PMCID: PMC6547711 DOI: 10.1038/s41598-019-44673-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 05/13/2019] [Indexed: 02/06/2023] Open
Abstract
Aim of the present study was to investigate the frequency and predictors of premature discontinuation or switch of ADP receptor blockers and its association with serious adverse events. For this purpose 571 consecutive ACS patients receiving ticagrelor (n = 258, 45%) or prasugrel (n = 313, 55%) undergoing PCI were enrolled in this prospective, observational, multicenter ATLANTIS-SWITCH substudy. Predictors of premature discontinuation or switch of antiplatelet therapy and their association with major adverse cardiovascular events and TIMI bleeding events were evaluated. Premature stop/switch was found in 72 (12.6%) patients: 34 (5.9%) stopped and 38 (6.7%) switched the ADP blocker. Ticagrelor treated patients were significantly more likely to stop/switch therapy as compared to prasugrel (15.9% vs. 9.2%, p = 0.016). We identified 4 independent predictors for stop/switch of ADP blocker: major surgery, need for oral anticoagulation (OAC), TIMI major bleeding and drug intolerance. TIMI major bleeding was a driver of stop/switch actions and occurred in 4.3% vs 0.2% in patients with vs without stop/switch (p = 0.001). The majority of stop/switch actions (75%) were physicians driven decisions. Importantly, stop/switch of therapy was not associated with increased risk of MACE (p = 0.936). In conclusion premature switch/stop of ADP blockers appears to be safe when mainly driven by physician’s decision and clinical indication.
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Affiliation(s)
- Max-Paul Winter
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Markus Wallner
- Department of Cardiology, Medical University of Graz, Graz, Austria.,Lewis Katz School of Medicine, Temple University, Cardiovascular Research Center, Philadelphia, PA, USA
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Ewald Kolesnik
- Department of Cardiology, Medical University of Graz, Graz, Austria
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11
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Joyce LC, Baber U, Claessen BE, Sartori S, Chandrasekhar J, Cohen DJ, Henry TD, Ariti C, Dangas G, Faggioni M, Aoi S, Gibson CM, Aquino M, Krucoff MW, Vogel B, Moliterno DJ, Sorrentino S, Colombo A, Chieffo A, Kini A, Guedeney P, Witzenbichler B, Weisz G, Steg PG, Pocock S, Mehran R. Dual-Antiplatelet Therapy Cessation and Cardiovascular Risk in Relation to Age. JACC Cardiovasc Interv 2019; 12:983-992. [DOI: 10.1016/j.jcin.2019.02.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/23/2019] [Accepted: 02/25/2019] [Indexed: 01/29/2023]
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12
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Wang TY, Kaltenbach LA, Cannon CP, Fonarow GC, Choudhry NK, Henry TD, Cohen DJ, Bhandary D, Khan ND, Anstrom KJ, Peterson ED. Effect of Medication Co-payment Vouchers on P2Y12 Inhibitor Use and Major Adverse Cardiovascular Events Among Patients With Myocardial Infarction: The ARTEMIS Randomized Clinical Trial. JAMA 2019; 321:44-55. [PMID: 30620370 PMCID: PMC6583585 DOI: 10.1001/jama.2018.19791] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Despite guideline recommendations, many patients discontinue P2Y12 inhibitor therapy earlier than the recommended 1 year after myocardial infarction (MI), and higher-potency P2Y12 inhibitors are underutilized. Cost is frequently cited as an explanation for both of these observations. OBJECTIVE To determine whether removing co-payment barriers increases P2Y12 inhibitor persistence and lowers risk of major adverse cardiovascular events (MACE). DESIGN, SETTING, AND PARTICIPANTS Cluster randomized clinical trial among 301 hospitals enrolling adult patients with acute MI (June 5, 2015, through September 30, 2016); patients were followed up for 1 year after discharge (final date of follow-up was October 23, 2017), with blinded adjudication of MACE; choice of P2Y12 inhibitor was per clinician discretion. INTERVENTIONS Hospitals randomized to the intervention (n = 131 [6436 patients]) provided patients with co-payment vouchers for clopidogrel or ticagrelor for 1 year (median voucher value for a 30-day supply, $137 [25th-75th percentile, $20-$339]). Hospitals randomized to usual care (n = 156 [4565 patients]) did not provide study vouchers. MAIN OUTCOMES AND MEASURES Independent coprimary outcomes were patient-reported persistence with P2Y12 inhibitor (defined as continued treatment without gap in use ≥30 days) and MACE (death, recurrent MI, or stroke) at 1 year among patients discharged with a prescription for clopidogrel or ticagrelor. RESULTS Among 11 001 enrolled patients (median age, 62 years; 3459 [31%] women), 10 102 patients were discharged with prescriptions for clopidogrel or ticagrelor (clopidogrel prescribed to 2317 [36.0%] in the intervention group and 2497 [54.7%] in the usual care group), 4393 of 6135 patients (72%) in the intervention group used the voucher, and follow-up data at 1 year were available for 10 802 patients (98.2%). Patient-reported persistence with P2Y12 inhibitors at 1 year was higher in the intervention group than in the control group (unadjusted rates, 5340/6135 [87.0%] vs 3324/3967 [83.8%], respectively; P < .001; adjusted difference, 2.3% [95% CI, 0.4% to 4.1%]; adjusted odds ratio, 1.19 [95% CI, 1.02 to 1.40]). There was no significant difference in MACE at 1 year between intervention and usual care groups (unadjusted cumulative incidence, 10.2% vs 10.6%; P = .65; adjusted difference, 0.66% [95% CI, -0.73% to 2.06%]; adjusted hazard ratio, 1.07 [95% CI, 0.93 to 1.25]). CONCLUSIONS AND RELEVANCE Among patients with MI, provision of vouchers to offset medication co-payments for P2Y12 inhibitors, compared with no vouchers, resulted in a 3.3% absolute increase in patient-reported persistence with P2Y12 inhibitors and no significant reduction in 1-year MACE outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02406677.
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Affiliation(s)
- Tracy Y. Wang
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | | | | | - David J. Cohen
- Saint Luke’s Mid America Heart Institute, University of Missouri–Kansas City School of Medicine
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13
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Dayoub EJ, Seigerman M, Tuteja S, Kobayashi T, Kolansky DM, Giri J, Groeneveld PW. Trends in Platelet Adenosine Diphosphate P2Y12 Receptor Inhibitor Use and Adherence Among Antiplatelet-Naive Patients After Percutaneous Coronary Intervention, 2008-2016. JAMA Intern Med 2018; 178:943-950. [PMID: 29799992 PMCID: PMC6145718 DOI: 10.1001/jamainternmed.2018.0783] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Current guidelines recommend prasugrel hydrochloride and ticagrelor hydrochloride as preferred therapies for patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). However, it is not well known how frequently these newer agents are being used in clinical practice or how adherence varies among the platelet adenosine diphosphate P2Y12 receptor (P2Y12) inhibitors. OBJECTIVES To determine trends in use of the different P2Y12 inhibitors in patients who underwent PCI from 2008 to 2016 in a large cohort of commercially insured patients and differences in patient adherence and costs among the P2Y12 inhibitors. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study used administrative claims from a large US national insurer (ie, UnitedHealthcare) from January 1, 2008, to December 1, 2016, comprising patients aged 18 to 64 years hospitalized for PCI who had not received a P2Y12 inhibitor for 90 days preceding PCI. The P2Y12 inhibitor filled within 30 days of discharge was identified from pharmacy claims. MAIN OUTCOMES AND MEASURES Proportion of patients filling prescriptions for P2Y12 inhibitors within 30 days of discharge by year, as well as medication possession ratios (MPRs) and total P2Y12 inhibitor copayments at 6 and 12 months for patients who received drug-eluting stents. RESULTS A total of 55 340 patients (12 754 [23.0%] women; mean [SD] age, 54.4 [7.1] years) who underwent PCI were included in this study. In 2008, 7667 (93.6%) patients filled a prescription for clopidogrel bisulfate and 521 (6.4%) filled no P2Y12 inhibitor prescription within 30 days of hospitalization. In 2016, 2406 (44.0%) patients filled clopidogrel prescriptions, 2015 (36.9%) filled either prasugrel or ticagrelor prescriptions, and 1045 (19.1%) patients filled no P2Y12 inhibitor prescription within 30 days of hospitalization. At 6 months, mean MPRs for patients who received a drug-eluting stent filling clopidogrel, prasugrel, and ticagrelor prescriptions were 0.85 (interquartile range [IQR], 0.82-1.00), 0.79 (IQR, 0.66-1.00), and 0.76 (IQR, 0.66-0.98) (P < .001), respectively; mean copayments for a 6 months' supply were $132 (IQR, $47-$203), $287 (IQR, $152-$389), and $265 (IQR, $53-$387) (P < .001), respectively. At 12 months, mean MPRs for clopidogrel, prasugrel, and ticagrelor were 0.76 (IQR, 0.58-0.99), 0.71 (IQR, 0.49-0.98), and 0.68 (IQR, 0.41-0.94) (P < .001), respectively; mean total copayments were $251 (IQR, $100-$371), $556 (IQR, $348-$730), and $557 (IQR, $233-$744) (P < .001), respectively. CONCLUSIONS AND RELEVANCE Between 2008 and 2016, increased use of prasugrel and ticagrelor was accompanied by increased nonfilling of prescriptions for P2Y12 inhibitors within 30 days of discharge. Prasugrel and ticagrelor had higher patient costs and lower adherence in the year following PCI compared with clopidogrel. The introduction of newer, more expensive P2Y12 inhibitors was associated with lower adherence to these therapies.
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Affiliation(s)
- Elias J Dayoub
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Matthew Seigerman
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Sony Tuteja
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia.,Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Daniel M Kolansky
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia.,Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Peter W Groeneveld
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia.,Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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14
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Zeymer U, Cully M, Hochadel M. Adherence to dual antiplatelet therapy with ticagrelor in patients with acute coronary syndromes treated with percutaneous coronary intervention in real life. Results of the REAL-TICA registry. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2018; 4:205-210. [DOI: 10.1093/ehjcvp/pvy018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/03/2018] [Indexed: 11/14/2022]
Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen, Bremserstrasse 79, Ludwigshafen/Rhein, Germany
- Institut für Herzinfarktforschung Ludwigshafen, Bremserstrasse 79, Ludwigshafen/Rhein, Germany
| | | | - Mathias Hochadel
- Institut für Herzinfarktforschung Ludwigshafen, Bremserstrasse 79, Ludwigshafen/Rhein, Germany
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15
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Frequency, Reasons, and Impact of Premature Ticagrelor Discontinuation in Patients Undergoing Coronary Revascularization in Routine Clinical Practice. Circ Cardiovasc Interv 2018; 11:e006132. [DOI: 10.1161/circinterventions.117.006132] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 04/02/2018] [Indexed: 11/16/2022]
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16
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Koskinas KC, Zanchin T, Klingenberg R, Gencer B, Temperli F, Baumbach A, Roffi M, Moschovitis A, Muller O, Tüller D, Stortecky S, Mach F, Lüscher TF, Matter CM, Pilgrim T, Heg D, Windecker S, Räber L. Incidence, Predictors, and Clinical Impact of Early Prasugrel Cessation in Patients With ST-Elevation Myocardial Infarction. J Am Heart Assoc 2018; 7:e008085. [PMID: 29654204 PMCID: PMC6015438 DOI: 10.1161/jaha.117.008085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/21/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early withdrawal of recommended antiplatelet treatment with clopidogrel adversely affects prognosis following percutaneous coronary interventions. Optimal antiplatelet treatment is essential following ST-segment elevation myocardial infarction (STEMI) given the increased risk of thrombotic complications. This study assessed the frequency, predictors, and clinical impact of early prasugrel cessation in patients with STEMI undergoing primary percutaneous coronary interventions. METHODS AND RESULTS We pooled patients with STEMI discharged on prasugrel in 2 prospective registries (Bern PCI Registry [NCT02241291] and SPUM-ACS (Inflammation and Acute Coronary Syndromes) [NCT01000701]) and 1 STEMI trial (COMFORTABLE-AMI (Comparison of Biomatrix Versus Gazelle in ST-Elevation Myocardial Infarction) [NCT00962416]). Prasugrel treatment status at 1 year was categorized as no cessation; crossover to another P2Y12-inhibitor; physician-recommended discontinuation; and disruption because of bleeding, side effects, or patient noncompliance. In time-dependent analyses, we assessed the impact of prasugrel cessation on the primary end point, a composite of cardiac death, myocardial infarction, and stroke. Of all 1830 included patients (17% women, mean age 59 years), 83% were treated with new-generation drug-eluting stents. At 1 year, any prasugrel cessation had occurred in 13.8% of patients including crossover (7.2%), discontinuation (3.7%), and disruption (2.9%). Independent predictors of any prasugrel cessation included female sex, age, and history of cerebrovascular event. The primary end point occurred in 5.2% of patients and was more frequent following disruption (hazard ratio 3.04, 95% confidence interval,1.34-6.91; P=0.008), without significant impact of crossover or discontinuation. Consistent findings were observed for all-cause death, myocardial infarction, and stent thrombosis following prasugrel disruption. CONCLUSIONS In this contemporary study of patients with STEMI, early prasugrel cessation was not uncommon and primarily involved change to another P2Y12-inhibitor. Disruption was the only type of early prasugrel cessation associated with statistically significant excess in ischemic risk within 1 year following primary percutaneous coronary interventions.
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Affiliation(s)
| | - Thomas Zanchin
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Roland Klingenberg
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Baris Gencer
- Division of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Fabrice Temperli
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | | | - Marco Roffi
- Division of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Aris Moschovitis
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Oliver Muller
- Service of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - David Tüller
- Department of Cardiology, Triemlispital, Zurich, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Francois Mach
- Division of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Thomas F Lüscher
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Christian M Matter
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Dik Heg
- CTU Bern and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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17
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Fanaroff AC, Kaltenbach LA, Peterson ED, Akhter MW, Effron MB, Henry TD, Wang TY. Antiplatelet Therapy Changes for Patients With Myocardial Infarction With Recurrent Ischemic Events: Insights Into Contemporary Practice From the TRANSLATE-ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) Study. J Am Heart Assoc 2018; 7:e007982. [PMID: 29437596 PMCID: PMC5850204 DOI: 10.1161/jaha.117.007982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/08/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Guidelines recommend P2Y12 inhibitor therapy for 1 year after myocardial infarction (MI), yet little guidance is provided on antiplatelet management for patients with recurrent ischemic events during that year. We describe changes in P2Y12 inhibitor type among patients with recurrent ischemic events in the first year after MI. METHODS AND RESULTS The TRANSLATE-ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study enrolled 12 365 patients with MI treated with percutaneous coronary intervention. We examined whether P2Y12 inhibitor choice changed among patients with recurrent MI, stent thrombosis, and/or unplanned revascularization during the first year after MI, and modeled factors associated with P2Y12 inhibitor intensification (changing clopidogrel to prasugrel or ticagrelor). In the first year after MI, 1414 patients (11%) had a total of 1740 recurrent ischemic events (771 recurrent MIs, 969 unplanned revascularizations, and 165 stent thromboses). Median time to the first recurrent ischemic event was 154 days (25th-75th percentiles, 55-287 days). Of those with recurrent ischemic events, 101 of 1092 (9.3%) occurring in clopidogrel-treated patients led to P2Y12 inhibitor intensification. Recurrent events involving stent thrombosis or MI were the strongest factors associated with P2Y12 inhibitor intensification, yet only 40% of patients with stent thrombosis and 14% of patients with recurrent MI had P2Y12 inhibitor intensification. Increasing age and longer time from the index MI were associated with lower likelihood for intensification. CONCLUSIONS Few patients after MI with a recurrent ischemic event who were taking clopidogrel switched to a more potent P2Y12 inhibitor, even after stent thrombosis events. Specific guidance is needed for patients who have recurrent ischemic events, particularly when closely spaced. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01088503.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Eric D Peterson
- Division of Cardiology, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Mohammed W Akhter
- Division of Cardiology, University of Massachusetts Medical Center, Worcester, MA
| | - Mark B Effron
- Division of Cardiology, John Ochsner Heart and Vascular Institute, New Orleans, LA
| | - Timothy D Henry
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Tracy Y Wang
- Division of Cardiology, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
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18
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Giustino G, Mehran R, Dangas GD, Kirtane AJ, Redfors B, Généreux P, Brener SJ, Prats J, Pocock SJ, Deliargyris EN, Stone GW. Characterization of the Average Daily Ischemic and Bleeding Risk After Primary PCI for STEMI. J Am Coll Cardiol 2017; 70:1846-1857. [PMID: 28982497 DOI: 10.1016/j.jacc.2017.08.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 08/07/2017] [Accepted: 08/13/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The risk of recurrent ischemic and bleeding events after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) may not be uniform over time, which may affect the benefit-to-risk ratio of guideline-recommended antithrombotic therapies in different intervals. OBJECTIVES This study sought to characterize the average daily ischemic rates (ADIRs) and average daily bleeding rates (ADBRs) within the first year after primary PCI for STEMI. METHODS Among 3,602 patients with STEMI who were enrolled in the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial, all ischemic and bleeding events, including recurrent events, were classified according to the timing of their occurrence as acute (≤24 h after PCI), subacute (1 day to 30 days), and late (30 days to 1 year). Patients were treated with aspirin and clopidogrel for the entire year. ADIRs included cardiac death, reinfarction, and definite stent thrombosis. ADBRs included non-coronary artery bypass graft-related Thrombolysis In Myocardial Infarction major and minor bleeding. ADIRs and ADBRs were calculated as the total number of events divided by the number of patient-days of follow-up in each interval assuming a Poisson distribution. Generalized estimating equations were used to test the absolute least square mean differences (LSMD) between ADIRs and ADBRs. RESULTS The ADIR and ADBR both exponentially decreased from the acute to the late periods (p < 0.0001). Although there were no significant differences in ADIR and ADBR in the acute phase (LSMD: +0.11%; 95% confidence interval [CI]: -0.35% to 0.58%; p = 0.63), the ADBR was greater than the ADIR in the subacute phase (LSMD: -0.39%; 95% CI: -0.58% to -0.20%; p < 0.0001). In the late phase, the ADIR exceeded the ADBR (LSMD: +1.51%; 95% CI: 1.04% to 1.98%; p < 0.0001). CONCLUSIONS After primary PCI, the ADIR and ADBR both markedly decreased over time. Although the rates for bleeding exceeded those for ischemia within 30 days, the daily risk of ischemia significantly exceeded the daily risk of bleeding beyond 30 days, supporting the use of intensified platelet inhibition during the first year after STEMI.
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Affiliation(s)
- Gennaro Giustino
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - George D Dangas
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, New York; Division of Cardiology, New York-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - Björn Redfors
- Cardiovascular Research Foundation, New York, New York
| | - Philippe Généreux
- Cardiovascular Research Foundation, New York, New York; Morristown Medical Center, Morristown, New Jersey
| | - Sorin J Brener
- Cardiovascular Research Foundation, New York, New York; Department of Medicine, New York Methodist Hospital, New York, New York
| | - Jayne Prats
- The Medicines Company, Parsippany, New Jersey
| | - Stuart J Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Gregg W Stone
- Cardiovascular Research Foundation, New York, New York; Division of Cardiology, New York-Presbyterian Hospital, Columbia University Medical Center, New York, New York.
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