Akshay Bagai1, Tracy Y Wang2, Shaun G Goodman3, Harold N Fisher4, Robert C Welsh5, Jean-Pierre Dery6, Xiang Zhang7, Yajun E Zhu7, Asim N Cheema8, Payam Dehghani9, Saleem A Kassam10, John Ducas11, Neil Brass12, Hahn Hoe Kim13, Anthony Fung14, Erick Schampaert15, Ata Ur Rehman Quraishi16, Shamir R Mehta17. 1. Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada. Electronic address: bagaia@smh.ca. 2. Duke Clinical Research Institute, Durham, NC, USA. 3. Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada; Canadian Heart Research Centre, Toronto, ON, Canada. 4. Eli Lilly Canada Inc., Toronto, ON, Canada. 5. Mazankowski Alberta Heart Institute, University of Alberta, Canadian VIGOUR Centre, Edmonton, AB, Canada. 6. Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, QC, Canada. 7. Eli Lilly and Company, Indianapolis, IN, United States. 8. Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada. 9. Prairie Vascular Research Network, Regina Qu'Appelle Health Region, Regina, SK, Canada. 10. Rouge Valley Health System, Toronto, ON, Canada. 11. Cardiac Sciences Program, St Boniface General Hospital, University of Manitoba, Winnipeg, MB, Canada. 12. Royal Alexandra Hospital, Edmonton, AB, Canada. 13. St. Mary's General Hospital, Kitchener, ON, Canada. 14. Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada. 15. Hôpital du Sacré-Coeur de Montréal, Université de Montréal, QC, Canada. 16. Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada. 17. Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
Abstract
BACKGROUND: After myocardial infarction (MI) treated with percutaneous coronary intervention (PCI), guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and an ADP receptor inhibitor (ADPri) for at least 1year. However, whether real-world Canadian practice patterns reflect this recommendation is unknown. METHODS: We studied 2175 MI patients treated with PCI and discharged from 26 Canadian hospitals between 12/2011 and 05/2013 in the Canadian Observational Antiplatelet sTudy (COAPT). Hierarchical Cox proportional hazard regression modeling was used to determine baseline demographic and clinical factors associated with duration of ADPri therapy post-discharge. RESULTS: At index-hospitalization discharge, 1597 (73%) patients were treated with clopidogrel, 220 (10%) with prasugrel, and 358 (17%) with ticagrelor. ADPri was discontinued prior to 1year in 474 (21.8%) patients; discontinuation rates were lowest for patients discharged on prasugrel (17.7%), compared with clopidogrel (22.5%) or ticagrelor (21.0%), (log rank test, p=0.03). In addition to regional variability, factors associated with shorter ADPri duration included older age, low body weight, Killip III/IV heart failure, atrial fibrillation, ticagrelor on discharge, and bare metal stent use, while longer ADPri duration was associated with history of prior MI. CONCLUSIONS: One in five PCI-treated MI patients did not complete Canadian guideline-recommended 1-year course of ADPri treatment. Premature ADPri discontinuation was most strongly associated with factors that increase the risk of bleeding. Further study is required to assess the clinical implications of premature ADPri discontinuation on patient outcomes.
BACKGROUND: After myocardial infarction (MI) treated with percutaneous coronary intervention (PCI), guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and an ADP receptor inhibitor (ADPri) for at least 1year. However, whether real-world Canadian practice patterns reflect this recommendation is unknown. METHODS: We studied 2175 MI patients treated with PCI and discharged from 26 Canadian hospitals between 12/2011 and 05/2013 in the Canadian Observational Antiplatelet sTudy (COAPT). Hierarchical Cox proportional hazard regression modeling was used to determine baseline demographic and clinical factors associated with duration of ADPri therapy post-discharge. RESULTS: At index-hospitalization discharge, 1597 (73%) patients were treated with clopidogrel, 220 (10%) with prasugrel, and 358 (17%) with ticagrelor. ADPri was discontinued prior to 1year in 474 (21.8%) patients; discontinuation rates were lowest for patients discharged on prasugrel (17.7%), compared with clopidogrel (22.5%) or ticagrelor (21.0%), (log rank test, p=0.03). In addition to regional variability, factors associated with shorter ADPri duration included older age, low body weight, Killip III/IV heart failure, atrial fibrillation, ticagrelor on discharge, and bare metal stent use, while longer ADPri duration was associated with history of prior MI. CONCLUSIONS: One in five PCI-treated MI patients did not complete Canadian guideline-recommended 1-year course of ADPri treatment. Premature ADPri discontinuation was most strongly associated with factors that increase the risk of bleeding. Further study is required to assess the clinical implications of premature ADPri discontinuation on patient outcomes.
Authors: Olivia R Ghosh-Swaby; Mary Tan; Akshay Bagai; Andrew T Yan; Shaun G Goodman; Shamir R Mehta; Harold N Fisher; Eric A Cohen; Thao Huynh; Warren J Cantor; Michel R Le May; Jean-Pierre Déry; Robert C Welsh; Jacob A Udell Journal: Clin Cardiol Date: 2018-03-25 Impact factor: 2.882