The underutilisation of dual antiplatelet therapy in acute coronary syndrome

Anastasius, Malcolm; Lau, Joseph; Hyun, Karice; D’Souza, Mario; Patel, Anushka; Rankin, Jamie; Walters, D.; Juergens, C.; Aliprandi-Costa, B.; Yan, Andrew T.; Chew, Derek P.; Brieger, David

doi:10.1016/j.ijcard.2017.04.077

Cited by 18 publications

(16 citation statements)

References 36 publications

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“…Similar result was demonstrated previously by Anastasius et al, that predictors for DAPT non-prescription in patients with ACS were CABG, use of warfarin, bleeding during hospitalisation, diagnosis of UA or NSTEMI (compared with STEMI), arrhythmia, hypertension and high Global Registry of Acute Coronary Events (GRACE) score. 11 Our study also found that older age, diagnosis of UA (compared with STEMI), diabetes, absent of use of GP IIb/IIIa or PPI and concurrent use of OAC were the predictors of clopidogrel use compared with prasugrel or ticagrelor as part of DAPT. Our study detected less predictors than the published study.…”

Section: Open Accesssupporting

confidence: 70%

“…Open access 2016. 11 Adherence rate of DAPT prescription in Hong Kong patients with ACS was lower than in other countries (average 46.8%, ranging 33.7%-68.0%).…”

Section: Discussionmentioning

confidence: 85%

“…Experience in Australia during 2009-2016 revealed that in patients with ACS without undergoing PCI, 52.6% of subjects received DAPT while 47.4% received single antiplatelet therapy. 11 The Sweden study also showed that use of DAPT in patients with ACS without PCI improved from 44% in 2009 to 50% in 2013. 10 Adherence to DAPT prescription in non-PCI ACS subjects was better in China, of which 81.8% of non-PCI NSTE-ACS subjects during 2014-2016 received DAPT.…”

Section: Discussionmentioning

confidence: 96%

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Trends of prescribing adherence of antiplatelet agents in Hong Kong patients with acute coronary syndrome: a 10-year retrospective observational cohort study

2020

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ObjectivesThe objective of this study is to examine the temporal trend of antiplatelet prescribing pattern during index hospitalisation discharge in Hong Kong (HK) acute coronary syndrome (ACS) population.DesignThe study is a retrospective observational cohort study.SettingThe study retrieved data from electronic health record from Hospital Authority (HA), HK.ParticipantsThe study included patients aged 18 years old or above, who were admitted to seven institutions under HA with diagnosis of ACS during 2008–2017.Primary and secondary outcome measuresThe primary outcome was the frequency of antiplatelet therapy prescription at the point of index hospitalisation discharge each year during 2008–2017. Association between demographics, baseline comorbidities, procedures and antiplatelet prescription were examined as secondary outcome using multivariate logistic regression model, with commonly used antiplatelet groups selected for comparison.ResultsAmong the included 14 716 patients, 5888 (40.0%) discharged with aspirin alone, 6888 (46.8%) discharged with dual antiplatelet therapy (DAPT) with clopidogrel, and 973 (6.6%) discharged with DAPT with prasugrel/ticagrelor. Prescribing rate of aspirin alone decreased substantially from 56.8% in 2008 to 27.5% in 2017. Utilisation of DAPT with clopidogrel increased from 33.7% in 2008 to 52.7% in 2017. Use of DAPT with prasugrel/ticagrelor increased from 0.3% in 2010 to 15.3% in 2017. Compared with those prescribed with DAPT with clopidogrel, male patients (adjusted OR (aOR) 1.34, 95% CI 1.09 to 1.65), patients with non-ST-elevation myocardial infarction (aOR 2.50, 1.98 to 3.16) or ST-elevation myocardial infarction (aOR 3.26, 2.59 to 4.09), use of glycoprotein IIb/IIIa (aOR 3.03, 2.48 to 3.68) or undergoing percutaneous coronary intervention (aOR 3.85, 3.24 to 4.58) or coronary artery bypass graft (aOR 6.52, 4.63 to 9.18) during index hospitalisation, concurrent use of histamine-2 receptor antagonists (aOR 1.35, 1.10 to 1.65) or proton pump inhibitors (aOR 3.57, 2.93 to 4.36) during index hospitalisation discharge were more likely to be prescribed with DAPT with prasugrel/ticagrelor. Patients with older age (aOR 0.97, 0.96 to 0.97), diabetes (aOR 0.68, 0.52 to 0.88), chronic kidney disease (aOR 0.43, 0.22 to 0.85) or concurrent use of oral anticoagulant (aOR 0.16, 0.07 to 0.42) were more likely to received DAPT with clopidogrel.ConclusionsUse of DAPT with prasugrel/ticagrelor was suboptimal yet improving during 2008–2017 in HK patients with ACS. Considering DAPT, predictors for clopidogrel prescription, compared with prasugrel/ticagrelor, were consistent with identified risk factors of bleeding.

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Section: Open Accesssupporting

confidence: 70%

“…Open access 2016. 11 Adherence rate of DAPT prescription in Hong Kong patients with ACS was lower than in other countries (average 46.8%, ranging 33.7%-68.0%).…”

Section: Discussionmentioning

confidence: 85%

Section: Discussionmentioning

confidence: 96%

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Trends of prescribing adherence of antiplatelet agents in Hong Kong patients with acute coronary syndrome: a 10-year retrospective observational cohort study

2020

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“…Other research in Australia has found underutilisation of DAPT following acute coronary events, defined by a prescription on hospital discharge, and estimates that only 70% of patients admitted for acute coronary syndrome were discharged with DAPT 21. Together with our work, this suggests problems with both initiation and cessation of DAPT in Australia.…”

Section: Discussionsupporting

confidence: 58%

Pharmaceutical use and costs in patients with coronary artery disease, using Australian observational data

et al. 2019

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ObjectivesWe aimed to estimate the annual pharmaceutical costs for patients with stable coronary artery disease, using Australian administrative data, comparing patients who had undergone interventional treatment with those had not. We also aimed to compare the duration of dual antiplatelet therapy (DAPT) prescription in the real-world, with recommended guidelines.DesignAn observational study using administrative data.ParticipantsWe used data from the QSkin study, a population-based prospective study assessing skin cancer risk. Participants were invited from the Queensland population, not based on perceived skin cancer risk, and had consented to future use of their data for approved research projects.Main outcome measuresWe calculated 12-month costs of pharmaceutical therapy for coronary artery disease for patients in each of three clinically relevant groups: medical therapy only, following coronary stent implantation and following coronary artery bypass graft surgery. We measured the duration of DAPT following stent implantation and total duration of DAPT, where it was prescribed, in the medical therapy only group.ResultsEstimated mean annual pharmaceutical costs were highest in the stent group at AUD$1920, compared with AUD$1481 in the medical therapy group, and AUD$881 in the coronary artery bypass group. There were similar rates of prescriptions of symptom relief drugs following stent insertion, compared with the medical therapy only group. The median duration of DAPT in the stent group was 16, and 31 months in the medical therapy group.ConclusionsOur results suggest that despite the common expectation that the burden of medical therapy is reduced following coronary stent insertion for stable coronary artery disease, this does not occur in practice. Many patients also appear to continue DAPT longer than guidelines recommend, which may put them at unnecessarily elevated risk of bleeding events.

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“…In a cohort of patients with ACS, CABG was an independent predictor for DAPT underutilization (odds ratio [OR] 0.09, 95%CI 0.05-0.14). (13)(14)(15) Suboptimal evidence implementation is not unique to antiplatelet therapy and ACS patients. Glynn et al reviewed random patient samples from 12 metropolitans in the United States (U.S.) and found that less than 55% received guideline-recommended care.…”

Section: Introductionmentioning

confidence: 99%

P2Y12 Inhibitor Utilization for Acute Coronary Syndrome in the Elderly: A Provincial Analysis From 2008 to 2018

Gupta

Belley‐Côté

Eqbal

et al. 2020

Preprint

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Background Guidelines recommend acetylsalicylic acid (ASA) and ticagrelor following acute coronary syndrome (ACS), but appropriate prescription practices lag. We analyzed the impact of government medication approval, national guideline updates, and publicly funded drug coverage plans on P2Y12 inhibitor utilization.Methods Accessing provincial databases, we obtained data for elderly ACS patients in Ontario, Canada between 2008 and 2018. Using an interrupted-time series, we evaluated types of P2Y12 inhibitors prescribed at discharge, and changes to their utilization following ticagrelor’s national approval by Health Canada, national antiplatelet therapy guidelines (by the Canadian Cardiovascular Society (CCS)), and ticagrelor's coverage by a publicly funded medication plan.Results We included 114,142 patients (49.4%-PCI and 7.7%-CABG). Proportion of PCI patients utilizing P2Y12 inhibitors increased from 73.4% to 86.9% (p<0.001) and 11.4% to 46.5% (p<0.001) for CABG patients. Among PCI patients, clopidogrel utilization declined monthly after 2010 national guidelines were published (0.7%; p<0.0001) and within the first month after ticagrelor’s national approval by Health Canada (5.3%; p=0.03). Among PCI patients, ticagrelor utilization increased within the first month (24.5%; p<0.0001) and continued increasing monthly (0.4%; p<0.0001) after its coverage by a publicly funded medication plan. Among CABG patients, ticagrelor’s coverage was associated with a monthly increase in its utilization (0.2%; p<0.0001). Among PCI patients, clopidogrel utilization declined within the first month (6.1%; p=0.003) and ticagrelor utilization increased monthly (0.3%; p=0.05) after 2012 CCS guidelines.Conclusion National guideline updates and drug coverage by a publicly funded medication plan significantly improved P2Y12 inhibitor utilization. Barriers to appropriate antiplatelet therapy in the surgical population must be explored.

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The underutilisation of dual antiplatelet therapy in acute coronary syndrome

Cited by 18 publications

References 36 publications

Trends of prescribing adherence of antiplatelet agents in Hong Kong patients with acute coronary syndrome: a 10-year retrospective observational cohort study

Trends of prescribing adherence of antiplatelet agents in Hong Kong patients with acute coronary syndrome: a 10-year retrospective observational cohort study

Pharmaceutical use and costs in patients with coronary artery disease, using Australian observational data

P2Y12 Inhibitor Utilization for Acute Coronary Syndrome in the Elderly: A Provincial Analysis From 2008 to 2018

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