Predictors of in-hospital de-escalation of P2Y12 inhibitors to clopidogrel in patients with acute myocardial infarction treated with percutaneous coronary intervention.
Presenter
Michael U Williams, MD, Warren Alpert Medical School of Brown University, Lifespan Health System, PROVIDENCE, RI
Michael U Williams, MD1, William R Lang, M.D.1, Tyler W Wark, M.D.1, Gerry Ovide, M.D.1, Rei Mitsuyama, M.D.1, Vishnu Kadiyala, M.D.1, Sokunvichet Long2, Mustapha O Kah3, Robert Emil Heinl IV, MD1, Esseim Sharma, MD1, Omar N Hyder, M.D., FSCAI1, Chirag Bavishi, M.D., FSCAI1, Kevin F Kennedy4, Herb D. Aronow, MD, MPH, FSCAI5 and J. Dawn Abbott, M.D., FSCAI6, (1)Warren Alpert Medical School of Brown University, Lifespan Health System, PROVIDENCE, RI, (2)Warren Alpert Medical School of Brown University, Providence, RI, (3)Towsen University, Towson, MD, (4)St. Luke's Hospital, Kansas City, MO, (5)Henry Ford Health, Detroit, MI, (6)Rhode Island Hospital, Barrington, RI
Keywords: Acute Coronary Syndromes (ACS), Cath Lab Administration, Coronary, Drug-eluting Stent (DES) and Pharmacotherapy
Background
Ticagrelor and prasugrel are recommended to reduce ischemic events in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). However, in clinical practice, patients are often switched from these potent P2Y12 inhibitors to clopidogrel at discharge (‘de-escalation’). We sought to assess the incidence and predictors of de-escalation.
Methods
Consecutive patients who received ticagrelor or prasugrel loading doses for AMI PCI at two tertiary centers between Jan 2015 - Mar 2019 who survived to discharge were included. Data were obtained from the electronic health record and institutional NCDR CathPCI data. Patients who were de-escalated to clopidogrel were compared with those who remained on potent P2Y12 inhibitors.
Results
Of 1922 patients in the overall cohort, 1155 (61.1%) were de-escalated (
Table). White race, private insurance and higher ischemic risk were negative predictors of de-escalation. Bleeding risk (PRECISE DAPT score) was not a significant predictor. In de-escalated patients, the rationale was not documented in 80%, due to cost in 14.9%, an adverse effect in 2.3%, bleeding risk in 1.8%, and research trial participation in 0.7% (p<0.001). All patients on oral anticoagulation were de-escalated (p<0.001) but this was documented as the reason for de-escalation in only 20%.
Conclusions
De-escalation occurred frequently in patients with AMI and was associated with non-clinical and clinical factors. Medical decision making was poorly documented and an area for improvement.
