Real-World Use of Novel P2Y12 Inhibitors in Patients with Acute Myocardial Infarction: A Treatment Paradox

Abstract

Objective: To assess the real-world use, clinical outcomes, and adherence to novel P₂Y₁₂ inhibitors. Methods: We evaluated 1,093 consecutive acute myocardial infarction patients undergoing a percutaneous intervention. Patients were derived from a prospective, multicenter, nationwide registry and were followed for 30 days; 381 patients (35%) received clopidogrel, 468 (43%) received prasugrel, and 244 (22%) received ticagrelor. Patients treated with clopidogrel were older and more likely to suffer from chronic renal failure and stroke and/or present with non-ST-elevation myocardial infarction (NSTEMI) (p < 0.01 for all). Independent predictors of undertreatment with novel P₂Y₁₂ inhibitors included: older age (OR 0.17; 95% CI 0.1-0.27, p < 0.0001), a prior stroke (OR 0.41; 95% CI 0.2-0.68, p = 0.008), and NSTEMI (OR 0.37; 95% CI 0.26-0.54, p < 0.0001). Results: Novel P₂Y₁₂ inhibitors were associated with a lower incidence of cardiovascular events, major bleeding, and/or death (7.6 vs.11%, HR 0.67; 95% CI 0.43-1, p = 0.05). However, after a multivariate analysis this trend was not statistically significant. Patients discharged with ticagrelor versus thienopyridines demonstrated a higher rate of crossover to other P₂Y₁₂ inhibitors (11 vs. 5%, p = 0.03). Conclusions: In a real-world cohort, there was an underutilization of novel P₂Y₁₂ inhibitors which was more pronounced in higher-risk subsets that might benefit from novel P₂Y₁₂ inhibitors at least as much as other patients.

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

“…8,28 Moreover, patients who have the highest ischemic risk often receive the least aggressive treatment, including both invasive and medical management; a phenomenon that has been termed the "treatment-risk paradox." [29][30][31][32] Suboptimal treatment of patients with multiple ischemic risk factors was highlighted in the Pattern of Repeat Cardiovascular Events…”

“…49 Patients with NSTEMI at high ischemic risk were also not treated optimally in the Myocardial Ischaemia National Audit Project (MINAP) registry, in which the use of guideline-indicated care for patients with NSTEMI decreased with increasing GRACE risk score, even though optimal guideline-indicated care was associated with greater survival gains for high-risk patients. 31 Adherence to guideline recommendations for the management of 51 Furthermore, data from national registries have indicated that patients with NSTEMI are more likely to receive clopidogrel than the potent P2Y 12 inhibitors, 29,52,53 which are generally preferentially recommended in international guidelines. 13,[15][16][17] There is also evidence to suggest that patients with NSTEMI may be less likely to be treated in academic medical centers than patients with STEMI, and therefore less likely to be directed to larger hospitals with catheterization laboratories; indicating some degree of referral bias toward patients with STEMI.…”

“…Despite the above recommendations and findings, patients with NSTEMI often receive less aggressive secondary prevention treatment than patients with STEMI . Moreover, patients who have the highest ischemic risk often receive the least aggressive treatment, including both invasive and medical management; a phenomenon that has been termed the “treatment‐risk paradox.”…”

Antithrombotic therapy for acute coronary syndrome: Past, present and future

“…Clopidogrel (300-600 mg loading dose, 75 mg daily dose) is recommended (Class I, LOE B) only for those patients who cannot receive ticagrelor or prasugrel or who require oral anticoagulation that may expose patients to an unacceptably high bleeding risk with prasugrel or ticagrelor (59). Despite these clear-cut recommendations, the utilisation of potent platelet inhibitors (prasugrel/ticagrelor) in the real world is still below its expectations (42,51,(60)(61)(62). Among other things, bleeding risk, treatment costs and issues with reimbursement in certain countries may explain this unexpected phenomenon.…”

Newer P2Y 12 Inhibitors: How Does the Interventional Cardiologist Choose?

“…Several other investigators have explored similar issues regarding the contemporary selection of antiplatelet therapy. 8 Perhaps the most important finding of this study was that prasugrel was used in 34% of ACS patients with a documented contraindication (history of stroke or transient ischemic accident, age >75 years, and body weight <60 kg). The selection of newer P2Y 12 inhibitors may be even more complex in European countries.…”