Predictors of de-escalation of P2Y12 inhibitors to clopidogrel in patients with acute myocardial infarction treated with percutaneous coronary intervention
Williams MU, et al. Cardiovasc Revasc Med. 2022:S1553-8389(22)00055-0.
- This retrospective study, the first study to detail the reasons for P2Y12 inhibitor de-escalation revealed that:
- Patients with AMI treated with PCI were frequently de-escalated to clopidogrel prior to discharge following initial treatment with potent P2Y12 inhibitor
- De-escalation was performed because of clinical/non-clinical factors and reasons were poorly documented by the clinicians, representing an area for improvement
Why This Matters
- In patients with ACS undergoing PCI, potent P2Y12 inhibitors ticagrelor and prasugrel have shown superior efficacy in reducing ischemic complications and stent thromboses vs clopidogrel, but with an increased bleeding risk.*
- Patients treated with more potent P2Y12 inhibitors are often deescalated to clopidogrel; however, the reasons were not well defined in the existing literature or registries.
This study assessed the incidence and predictors of in-hospital de-escalation from a potent P2Y12 inhibitor to clopidogrel in a cohort of patients with AMI PCI.
A retrospective study was conducted in two tertiary centers at USA using data obtained from the electronic health record and institutional NCDR CathPCI.
- Consecutive patients who received ticagrelor or prasugrel loading dose for AMI PCI with a drug eluting stent between Jan 2015 and Mar 2019 who survived to discharge.
- Patients de-escalated to clopidogrel were compared with those who remained on potent P2Y12 inhibitors through the time of discharge.
- The risk of bleeding prediction for all patients were determined using the PRECISE-DAPT score.
- Manual chart review of all patients was performed to identify the documented reason(s) for P2Y12 de-escalation.
Of the 1,818 included patients in the overall cohort, 1,146 (63%) patients underwent P2Y12 inhibitor de-escalation. (age = 65.1 ± 13.1 years; men = 69%)
|PATIENTS ON MEDICATIONS||
|DE-ESCALATION GROUP VS NO DE-ESCALATION GROUP|
|AGE||65.1 years vs 63.7 years|
|BLACK RACE||6.0% vs 2.3%|
|CAUCASIAN RACE||91% vs 94.6%|
|DIABETES PREVALENCE||30.2% vs 37.2%|
|PRIVATE INSURANCE||76.0% vs 83.2%|
|BLEEDING RISK||Similar in both groups|
|PCI COMPLEXITY||Less complex PCI|
|FACTORS ASSOCIATED WITH DE-ESCALATION|
|BIFURCATION LESION INTERVENTION||
|GREATER NUMBER OF STENTS||
|DECISION FOR DE-ESCALATION|
- High number of patients de-escalated without a documented reason.
- Data on patient preferences were not collected.
- This study was not powered to analyze separately ticagrelor and prasugrel, and lesion subsets such as left main or chronic total occlusions.
* Evidence suggest that tailoring antiplatelet regimens based on patient’s bleeding and ischemic risk may improve outcomes thana universally applied strategy
† While prevalence of known coronary artery disease was high and they were at ischemic risk
ABBREVIATIONS:ACS, acute coronary syndrome; AMI, acute myocardial infarction; CI, confidence interval; MI, myocardial infarction; OR, oddsratio; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction
Williams MU, Lang WR, Wark T, Ovide G, Mitsuyama R, Kadiyala V, et al. Predictors of in-hospital de-escalation of P2Y12 inhibitors to clopidogrel in patients with acute myocardial infarction treated with percutaneous coronary intervention. Cardiovasc Revasc Med. 2022:S1553-8389(22)00055-0. doi: 10.1016/j.carrev.2022.01.029. Epub ahead of print. PMID: 35181265.