Opportunities for improvement in anti-thrombotic therapy and other strategies for the management of acute coronary syndromes: Insights from EPICOR, an international study of current practice patterns

Bueno, Héctor; Sinnaeve, Peter; Annemans, Lieven; Danchin, Nicolás; Licour, Muriel; Medina, Jesús; Pocock, Stuart J.; Sánchez-Covisa, Joaquín; Storey, Robert F.; Jukema, J. Wouter; Zeymer, Uwe; Werf, Frans Van de

doi:10.1177/2048872614565912

Cited by 43 publications

(34 citation statements)

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“…At the time when the EPICOR study was conducted, none of the enrolled patients in Poland was initially treated with fibrinolytic therapy. In contrast, in other countries this type of initial treatment is used in 17.3% of patients with ACS, with the most frequently used agent being tenecteplase (used in 7.9% of patients with ACS) [11]. This observed predominance of a primary invasive approach in Poland seems to be related to high availability of this therapy.…”

Section: Discussionmentioning

confidence: 60%

“…The loading dose of ASA was the same across all countries, but the maintenance dose was lower in Poland (75 mg/day) than in other countries (100 mg). In addition, in other countries the newer antiplatelet medications like prasugrel were used more frequently than in Poland (for STEMI: 1.0% vs. 11.5% vs.; for NSTEMI/UA: 0.6% vs. 4.6%) [11]. This was probably related to the fact that these newer antiplatelet drugs are relatively unavailable for patients due to reimbursement of the drugs in Poland.…”

Section: Discussionmentioning

confidence: 93%

“…As many as 96.2% of STEMI and 73.8% of NSTEMI/UA patients were treated with primary PCI, while in the remaining countries involved in the EPICOR study this ratio was significantly lower: 49.3% for STEMI and 40.9% for NSTEMI/UA patients [11]. At the time when the EPICOR study was conducted, none of the enrolled patients in Poland was initially treated with fibrinolytic therapy.…”

Section: Discussionmentioning

confidence: 99%

“…Sample size calculations and description of statistical analysis for the total EPICOR population has already been described [10,11]. In the present analysis, descriptive statistics of variables were analysed.…”

Section: Discussionmentioning

confidence: 99%

“…The EPICOR study was a multinational, multicentre, observational, prospective, longitudinal cohort study, aimed at evaluation of the of the clinical approaches to the treatment of ACS in a spectrum of cardiology centres [10,11]. The study collected and evaluated data from 20 countries across Europe and Latin America for a total of 10,568 patients treated in 555 hospitals.…”

Section: Discussionmentioning

confidence: 99%

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Current patterns of antithrombotic and revascularisation therapy in patients hospitalised for acute coronary syndromes. Data from the Polish subset of the EPICOR study

Wojtkowska

Stępińska²,

Stępień-Wojno³

et al. 2017

Kardiol Pol

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A b s t r a c tBackground: Cardiovascular disease is the leading cause of mortality and morbidity in developed countries, including Poland. Antithrombotic drugs play a crucial role in the management of acute coronary syndromes (ACS). Recent clinical trials have demonstrated the efficacy and safety profiles of new antiplatelet and anticoagulant agents, which may be used as add-on therapy or replacements for older drugs. The long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients (EPICOR) is a prospective international observational study (NCT01171404) designed to describe the use of antithrombotic management strategies for the treatment of ACS during the acute phase and over a follow-up period of up to two years from the index event. A total of 608 patients from 26 hospitals in Poland were enrolled into the registry between September 2010 and March 2011. Aim:The aim of this work was to summarise data on pre-hospital and in-hospital and revascularisation therapy in 608 patients enrolled into the registry in Poland. Methods:The registry collected the records of patients who were hospitalised for ACS within 24 h of symptom onset and who had a final diagnosis of unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), or ST-segment elevation myocardial infarction (STEMI), and survived to discharge. Results:Among 608 enrolled patients, 291 had a final diagnosis of STEMI and 317 had a final diagnosis of NSTEMI/UA. Patients with NSTEMI/UA were generally at higher cardiovascular risk than patients with STEMI. Before admission to the hospital antiplatelet drugs (acetylsalicylic acid [ASA] and/or clopidogrel) were administered more frequently to STEMI than to NSTEMI/UA patients. Glycoprotein (GP) IIb/IIIa inhibitors were used in almost half of the STEMI patients and in nearly 10% of NSTEMI/UA patients. The combinations of antiplatelet drugs included ASA + clopidogrel (predominantly in NSTEMI/UA) or ASA + clopidogrel + GPIIb/IIIa inhibitor (predominantly in STEMI), while other possible combinations were not used. Almost all STEMI patients (96.2%) and the clear majority of NSTEMI/UA patients (73.8%) were subjected to percutaneous coronary intervention (PCI), while coronary artery bypass grafting was performed in only 2.5% of the NSTEMI/UA patients. At the time of discharge from hospital almost all patients with STEMI received ASA together with clopidogrel, but this strategy was used only in 91.5% of patients with NSTEMI/UA (p < 0.05). Unfractionated heparin was used in 62% of patients, low-molecular weight heparin in 35%, fondaparinux in 0.7%, and bivalirudin in none of the studied patients.Conclusions: Among patients with ACS enrolled to the EPICOR study in Poland, antiplatelet therapy was started in the pre-hospital phase in approximately one-third of the STEMI patients and in one out of ten of the NSTEMI/UA patients. The initial antiplatelet therapy was mostly based on ASA + clopidogrel and was followed by a combination of ASA + clopidogrel + GPIIb/IIIa inhibito...

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Section: Discussionmentioning

confidence: 60%

Section: Discussionmentioning

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Current patterns of antithrombotic and revascularisation therapy in patients hospitalised for acute coronary syndromes. Data from the Polish subset of the EPICOR study

Wojtkowska

Stępińska²,

Stępień-Wojno³

et al. 2017

Kardiol Pol

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Regional variations in hospital management and post-discharge mortality in patients with non-ST-segment elevation acute coronary syndrome

et al. 2018

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De-escalation from ticagrelor to clopidogrel in acute coronary syndrome patients: a systematic review and meta-analysis

Angiolillo

Patti

Chan

et al. 2019

J Thromb Thrombolysis

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De-escalation from ticagrelor to clopidogrel in acute coronary syndrome (ACS) may occur for a variety of reasons, including side effects (bleeding and non-bleeding) and costs. This study sought to assess the prevalence of de-escalation from ticagrelor to clopidogrel and the occurrence of adverse clinical outcomes following de-escalation. We conducted a systematic review of clinical trials and real-world studies in ACS patients treated with ticagrelor. Real-world data on the prevalence of de-escalation during hospitalization or at discharge, after hospital discharge, and during the whole study period were included for meta-analysis. Major adverse cardiovascular events (MACE) and bleeding events occurring after de-escalation were also assessed. A total of 12 studies were eligible for meta-analysis of the prevalence of de-escalation. De-escalation from ticagrelor to clopidogrel therapy occurred with a mean prevalence of 19.8% [95% confidence interval (CI) 11.2–28.4%]. De-escalation occurred more frequently in-hospital or at discharge than after hospital discharge (23.7% vs. 15.8%). For assessment of clinical outcomes, a total of six studies were eligible for meta-analysis. Mean rate of MACE for patients with de-escalation was 2.1% (95% CI 1.1–4.1%) and the rate of major bleeding events was 1.3% (95% CI 0.4–4.5%). In conclusion, de-escalation commonly occurs in real-world practice. Although rates of major cardiovascular and bleeding events in this analysis were generally low, the profile of patients suitable for de-escalation, the impact of de-escalation on adverse clinical outcomes and how this is affected by the timing after index ACS warrants further large-scale investigation. Electronic supplementary material The online version of this article (10.1007/s11239-019-01860-7) contains supplementary material, which is available to authorized users.

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Opportunities for improvement in anti-thrombotic therapy and other strategies for the management of acute coronary syndromes: Insights from EPICOR, an international study of current practice patterns

Cited by 43 publications

References 20 publications

Current patterns of antithrombotic and revascularisation therapy in patients hospitalised for acute coronary syndromes. Data from the Polish subset of the EPICOR study

Current patterns of antithrombotic and revascularisation therapy in patients hospitalised for acute coronary syndromes. Data from the Polish subset of the EPICOR study

Regional variations in hospital management and post-discharge mortality in patients with non-ST-segment elevation acute coronary syndrome

De-escalation from ticagrelor to clopidogrel in acute coronary syndrome patients: a systematic review and meta-analysis

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