Malcolm Anastasius1, Jerrett K Lau1, Karice Hyun2, Mario D'Souza3, Anushka Patel2, Jamie Rankin4, Darren Walters5, Craig Juergens6, Bernadette Aliprandi-Costa7, Andrew T Yan8, Shaun G Goodman8, Derek Chew9, David Brieger10. 1. Department of Cardiology, Concord Repatriation General Hospital, University of Sydney, Sydney, Australia. 2. The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia. 3. School of Public Health, University of Sydney, Sydney, Australia; Clinical Research Centre, Sydney Local Health District, Sydney, Australia. 4. Department of Cardiology, Fiona Stanley Hospital, Perth, Australia. 5. Department of Cardiology, Prince Charles Hospital, University of Queensland, Brisbane, Australia. 6. Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia. 7. Sydney Medical School, The University of Sydney, Sydney, Australia. 8. Division of Cardiology, St. Michaels Hospital, University of Toronto, Toronto, Canada. 9. Department of Cardiology, Flinders University, Adelaide, Australia. 10. Department of Cardiology, Concord Repatriation General Hospital, University of Sydney, Sydney, Australia. Electronic address: dbrieger@uni.sydney.edu.au.
Abstract
BACKGROUND: Despite guideline recommendation of dual antiplatelet therapy (DAPT) in treating ACS, DAPT is underutilized. Our objective was to determine independent predictors of DAPT non-prescription in ACS and describe pattern of DAPT prescription over time. METHODS: Patients presenting to 41 Australian hospitals with an ACS diagnosis between 2009 and 2016 were stratified according to discharge prescription with DAPT and single antiplatelet therapy (SAPT) or no antiplatelet therapy. Multiple stepwise logistic regression, accounting for within hospital clustering, was used to determine the independent predictors of DAPT non-prescription, defined as discharge with SAPT alone or no antiplatelet agent. RESULTS: 8939 patients survived to discharge with an ACS diagnosis. Of these, 6294 (70.4%) patients were discharged on DAPT, 2154 (24.1%) on SAPT and 491 (5.5%) on no antiplatelet agent. Independent predictors of DAPT non-prescription in the overall cohort were: in-hospital CABG (OR 0.09, 95%CI 0.05-0.14), discharge with warfarin (0.10 (0.07-0.14)), in hospital major bleeding (0.48 (0.34-0.67), diagnosis of unstable angina (0.35, (0.27-0.45)), non-ST-elevation myocardial infarction (0.67 (0.57-0.78)) [both vs. ST-segment elevation myocardial infarction], in hospital atrial arrhythmia (0.72 (0.60-0.86)), history of hypertension (0.83 (0.73-0.94)) and GRACE high risk (0.83 (0.71-0.98)). There was an increase in prescription of DAPT and a shift towards ticagrelor over clopidogrel for ACS from 2013 to 2016 (p<0.0001), but no overall change in the frequency of DAPT prescription over the entire study period. CONCLUSION: This study revealed high-risk ACS subgroups who do not receive optimal DAPT. Strategies are necessary to bridge the treatment gap in ACS antiplatelet management.
BACKGROUND: Despite guideline recommendation of dual antiplatelet therapy (DAPT) in treating ACS, DAPT is underutilized. Our objective was to determine independent predictors of DAPT non-prescription in ACS and describe pattern of DAPT prescription over time. METHODS:Patients presenting to 41 Australian hospitals with an ACS diagnosis between 2009 and 2016 were stratified according to discharge prescription with DAPT and single antiplatelet therapy (SAPT) or no antiplatelet therapy. Multiple stepwise logistic regression, accounting for within hospital clustering, was used to determine the independent predictors of DAPT non-prescription, defined as discharge with SAPT alone or no antiplatelet agent. RESULTS: 8939 patients survived to discharge with an ACS diagnosis. Of these, 6294 (70.4%) patients were discharged on DAPT, 2154 (24.1%) on SAPT and 491 (5.5%) on no antiplatelet agent. Independent predictors of DAPT non-prescription in the overall cohort were: in-hospital CABG (OR 0.09, 95%CI 0.05-0.14), discharge with warfarin (0.10 (0.07-0.14)), in hospital major bleeding (0.48 (0.34-0.67), diagnosis of unstable angina (0.35, (0.27-0.45)), non-ST-elevation myocardial infarction (0.67 (0.57-0.78)) [both vs. ST-segment elevation myocardial infarction], in hospital atrial arrhythmia (0.72 (0.60-0.86)), history of hypertension (0.83 (0.73-0.94)) and GRACE high risk (0.83 (0.71-0.98)). There was an increase in prescription of DAPT and a shift towards ticagrelor over clopidogrel for ACS from 2013 to 2016 (p<0.0001), but no overall change in the frequency of DAPT prescription over the entire study period. CONCLUSION: This study revealed high-risk ACS subgroups who do not receive optimal DAPT. Strategies are necessary to bridge the treatment gap in ACS antiplatelet management.
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