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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

Patients on medications
  • Ticagrelor = 92%
  • Prasugrel = 8%
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
Patient History†
  • A significant number of patients with history of myocardial infarction (20.4%), prior PCI (21.6%), were de-escalated (P <0.001)
  • The pre- and post-PCI hemoglobin, creatinine, and post-procedure bleeding events were similar in patients in both the groups
  • No difference in de-escalation rates by clinical presentation, STEMI vs non-STEMI
  • Patients receiving glycoprotein IIb/IIIa inhibitor were less likely to be de-escalated (P = 0.034)
 

Factors Associated with De-escalation

Positive Association
Older Age
  • OR: 1.2 (95% CI: 1.08–1.34), P = 0.001
Negative Association
Caucasian Race
  • OR: 0.5 (95% CI: 0.33–0.77), P = 0.002
Prior MI
  • OR: 0.7 (95% CI: 0.5–0.97), P = 0.032
Bifurcation Lesion Intervention
  • OR: 0.71 (95% CI: 0.53–0.95), P = 0.019
Greater number of Stents
  • OR: 0.82 (95% CI: 0.75–0.91), P = 0.0001
  • There was no change in rates of de-escalation over time during the study

Decision for De-escalation

  • Not documented in 75.9% of patients
  • Among those with a documented reason, the most common reasons were:
  • Medication cost = 14.9%
  • Bleeding risk = 6%

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

Abbreviations

ACS, acute coronary syndrome; AMI, acute myocardial infarction; CI, confidence interval; MI, myocardial infarction; OR, odds ratio; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction.

Reference

  1. 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.

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MAT-IN-2301961 - 09/2023