Prevalence, Predictors, and Outcomes of Premature Discontinuation of Thienopyridine Therapy After Drug-Eluting Stent Placement

Abstract

Background-Although drug-eluting stents (DES) significantly reduce restenosis, they require 3 to 6 months of thienopyridine therapy to prevent stent thrombosis. The rate and consequences of prematurely discontinuing thienopyridine therapy after DES placement for acute myocardial infarction (MI) are unknown. Methods and Results-We used prospectively collected data from a 19-center study of MI patients to examine the prevalence and predictors of thienopyridine discontinuation 30 days after DES treatment. We then compared the mortality and cardiac hospitalization rates for the next 11 months between those who stopped and those who continued thienopyridine therapy. Among 500 DES-treated MI patients who were discharged on thienopyridine therapy, 68 (13.6%) stopped therapy within 30 days. Those who stopped were older, less likely to have completed high school or be married, more likely to avoid health care because of cost, and more likely to have had preexisting cardiovascular disease or anemia at presentation. They were also less likely to have received discharge instructions about their medications or a cardiac rehabilitation referral. Patients who stopped thienopyridine therapy by 30 days were more likely to die during the next 11 months (7.5% versus 0.7%, PϽ0.0001; adjusted hazard ratioϭ9.0; 95% confidence intervalϭ1.3 to 60.6) and to be rehospitalized (23% versus 14%, Pϭ0.08; adjusted hazard ratioϭ1.5; 95% confidence intervalϭ0.78 to 3.0). Conclusions-Almost 1 in 7 MI patients who received a DES were no longer taking thienopyridines by 30 days.Prematurely stopping thienopyridine therapy was strongly associated with subsequent mortality. Strategies to improve the use of thienopyridines are needed to optimize the outcomes of MI patients treated with DES.

Can Phone-Based Motivational Interviewing Improve Medication Adherence to Antiplatelet Medications After a Coronary Stent Among Racial Minorities? A Randomized Trial

“…1 The premature discontinuation of these medications 1 is associated with an increased risk of instent thrombosis, cardiovascular events and death. [2][3][4][5][6] Unfortunately, lack of medication adherence is common and is associated with significant health care costs and mortality. 7,8 Vulnerable groups such as racial minorities and the elderly have a higher risk of poor adherence.…”

Hospital Variation in Premature Clopidogrel Discontinuation After Drug‐Eluting Stent Placement in the Veterans Affairs (VA) Healthcare System

“…In an Italian cohort from 2 hospitals in northern Italy, 8.8% of patients had discontinued clopidogrel by 12 months 3. In a study of AMI patients from the Prospective Registry Evaluating Outcomes After Myocardial Infarctions: Events and Recovery registry, 13.6% of patients were not taking clopidogrel at 30 days after hospitalization for AMI and DES placement 5. There are several potential explanations for the lower rates of premature discontinuation in the VA health care system compared with prior studies.…”

Extended Duration Dual Antiplatelet Therapy and Mortality: A Systematic Review and Meta-Analysis

“…Conversely, widespread fear over the risks of continued thienopyridine use could results in inappropriate discontinuation, leading to an increased risk of ischemic events. 24,25 This is particularly important in light of the renewed observation within the DAPT trial that even late planned thienopyridine discontinuation 30 months after PCI was associated with a detectable increase in risk of ischemic events. Therefore, it was imperative to examine the impact of extended treatment with DAPT on mortality among a wide group of cardiovascular patients, to help frame trialspecific results against of the larger body of prior literature evaluating DAPT duration.…”