Delay in Filling First Clopidogrel Prescription After Coronary Stenting Is Associated With an Increased Risk of Death and Myocardial Infarction

Abstract

BackgroundPatients frequently experience difficulties with medication compliance after hospital discharge. We investigated the effect of a delay in filling a first clopidogrel prescription after hospital discharge on clinical outcomes subsequent to coronary stenting.Methods and ResultsHospital administrative, community pharmacy, and cardiac revascularization data were determined for all patients receiving a coronary stent in British Columbia 2004–2006 with follow‐up out to 2 years. Cox's proportional hazard regression analysis, adjusting for baseline demographics and procedural variables, was performed to examine the effects of delay in filling a clopidogrel prescription after hospital discharge on clinical outcomes.Of 15 629 patients treated with coronary stents, 3599 received at least 1 drug‐eluting stent (DES), whereas 12 030 received bare metal stents (BMS) alone. In total, 1064 (30%) and 3758 (31%) patients in the DES and BMS groups, respectively, failed to fill a prescription within 3 days of discharge (median, 1 day; interquartile range [IQR], 1 to 3). After regression analysis, a delay of >3 days was predictive of mortality and recurrent myocardial infarction (MI) irrespective of stent type (DES: hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.7 to 3.4; and HR, 2.0; 95% CI, 1.5 to 2.7, respectively, and BMS: HR, 2.2; 95% CI, 1.9 to 2.6; and HR, 1.8; 95% CI, 1.5 to 2.1, respectively). This excess hazard was greatest in the 30‐day period immediately after hospital discharge (mortality: HR, 5.5; 95% CI, 3.5 to 8.6; and MI: HR, 3.1; 95% CI, 2.4 to 4.0, for all patients).ConclusionsDelays in patients filling their first prescription for clopidogrel after coronary stenting are common and associated with adverse clinical outcomes, irrespective of stent type. Strategies to reduce delays have the potential to improve clinical outcomes.

Medication adherence in patients after percutaneous coronary intervention due to acute myocardial infarction: From research to clinical implications

“…Even a delay in filling the first prescription after invasive coronary treatment could be associated with unexpected, adverse clinical outcomes. Based on data obtained from a British-Columbian consortium, the postponement of handing in a prescription, for more than 3 days projected with possible mortality and/or recurrent AMI [39]. These results are consistent with other studies that analyzed patients who received their prescription for clopidogrel successfully on the day of hospital discharge after DES implantation against patients who delayed the purchase of clopidogrel.…”

Clinical factors associated with initiation of and persistence with ADP receptor-inhibiting oral antiplatelet treatment after acute coronary syndrome: a nationwide cohort study from Finland

“…Premature discontinuation of OAP therapy has been defined as an independent risk factor for thrombotic events. 25 For clopidogrel, in addition to 12 months, drops also occurred at 1, 3 and 6 months without observable improvement during the study period. Old age, dementia, high Charlson Comorbidity Score, atrial fibrillation and, particularly, warfarin treatment were indicators for not completing 1 year of OAP medication.…”

“…In a UK study, the median time for filling clopidogrel prescription after hospital discharge was 1 day, but one-third of the patients failed to fill their prescription within 3 days. 25 The risk of long-term adverse events increased with the time delay and the patients who never filled a clopidogrel prescription were at greatest risk. In our data, only half of the patients with ACS became OAP users after discharge, but of those who did fill the prescription, 90% did it within 1 day.…”

Evaluation of Pharmacist Medication Education and Post-discharge Follow-up in Reducing Readmissions in Patients With ST-Segment Elevation Myocardial Infarction (STEMI)

“…A 2-year study conducted in British Columbia found that a delay of more than 3 days in filling a first prescription of clopidogrel after hospital discharge was associated with an increased risk of death, readmission with MI, and the combined end point of death and readmission for MI during long-term follow-up. 4 Furthermore, up to 14.5% of STEMI patients in the United States were readmitted within 30 days. 5 STEMI readmission rate can be as high as 19.9%, as reported in another study.…”