In-Hospital Switching Between Clopidogrel and Prasugrel Among Patients With Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention

Abstract

Background-Although randomized clinical trials have compared clopidogrel with higher potency ADP receptor inhibitors (ADPris) among patients with myocardial infarction, little is known about the frequency and factors associated with switching between ADPris in clinical practice. Methods and Results-We studied 47 040 patients with myocardial infarction treated with percutaneous coronary intervention, who received either clopidogrel or prasugrel within 24 hours of admission at 361 US hospitals from July 2009 to June 2011 using the merged Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines and CathPCI Registry database. Hierarchical logistic regression modeling was used to determine factors independently associated with in-hospital ADPri switching. Among 40 531 patients treated initially in-hospital with clopidogrel, 2125 (5.2%) were discharged on prasugrel; this frequency steadily increased from 0% to 7% during the study period. Among 6509 patients treated initially in-hospital with prasugrel, 751 (11.5%) were discharged on clopidogrel. The frequency of this switch increased from 6% to 18% during the first 2 quarters of the study period and decreased to 9% by the end. Switching clopidogrel to prasugrel was associated with high-risk angiographic characteristics (thrombotic, long, and bifurcating lesions), reinfarction in-hospital, and private health insurance coverage. Older age, previous cerebrovascular event, in-hospital coronary artery bypass grafting, in-hospital bleeding, and warfarin use at discharge were associated with switching prasugrel to clopidogrel. Conclusions-Clopidogrel and prasugrel are not uncommonly switched in-hospital in patients with myocardial infarction undergoing percutaneous coronary intervention. In contemporary US practice, in addition to risk for bleeding and recurrent ischemic events, medical drug coverage is a major determinant of ADPri selection. (Circ Cardiovasc Interv. 2014;7:585-593.)

Guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention (TROPICAL-ACS): a randomised, open-label, multicentre trial

“…6,[8][9][10][11][24][25][26] Nevertheless, there is little evidence until now to justify switching regimens. TROPICALACS is currently the only trial investigating a concept of guided deescalation of P2Y 12 inhibition in an allcomers cohort of patients with acute coronary syndrome.…”

Antiplatelet Therapy Changes for Patients With Myocardial Infarction With Recurrent Ischemic Events: Insights Into Contemporary Practice From the TRANSLATE‐ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) Study

“…A previous analysis examined switching from clopidogrel to a higher‐potency P2Y 12 inhibitor during the index MI hospitalization; younger age, private health insurance, and presentation with STEMI were associated with intensification of P2Y 12 inhibitor therapy, whereas prior history of atrial fibrillation, stroke, peripheral artery disease, or heart failure were associated with clopidogrel continuation 17. Patients switched to a higher‐potency P2Y 12 inhibitor were more likely to have had a recurrent MI during their index hospitalization than patients continued on clopidogrel.…”

“…Recurrent ischemic events while receiving clopidogrel therapy may affect physician decision making because of perceived clopidogrel “failure,” although these events may not necessarily reflect inadequate platelet inhibition. In patients with ACS, in‐hospital reinfarction while taking clopidogrel is associated with a higher likelihood of a switch to prasugrel 17. Postdischarge switching is rare, and most switches are from prasugrel or ticagrelor to clopidogrel, driven by cost considerations 18.…”

Bedside stratification of patients according to CYP2C19*2 genotype

“…It was also shown that clopidogrel was effective enough in the carriers of wild-type (*1*1) CYP2C19, which represents a normal metabolism rate of this drug (Reese et al, 2012). In addition, only up to one-fourth of the prasugrel-treated patients are discharged from hospital for antiplatelet treatment at home (Sandhu et al, 2013;Bagai et al, 2014).…”