Predictors of de-escalation of P2Y12 inhibitors to clopidogrel in patients with acute myocardial infarction treated with percutaneous coronary intervention

Key takeaway

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.

Study design

A retrospective study was conducted in two tertiary centers at USA using data obtained from the electronic health record and institutional NCDR CathPCI.

Patients included

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.

Analyses

Patients de-escalated to clopidogrel were compared with those who remained on potent P2Y12 inhibitors through the time of discharge.

Data evaluated

• 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.

Key results

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 characteristics

Factors Associated with De-escalation

Decision for De-escalation

Key limitations

• 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 than a universally applied strategy

^† While prevalence of known coronary artery disease was high and they were at ischemic risk

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