Ticagrelor Use in Acute Myocardial Infarction: Insights From the National Cardiovascular Data Registry

Abstract

BackgroundTicagrelor is a P2Y12 receptor inhibitor with superior clinical efficacy compared with clopidogrel. However, it is associated with reduced efficacy when combined with a high‐dose aspirin.Methods and ResultsPatients in the acute coronary treatment and intervention outcomes network (ACTION) Registry‐Get With The Guidelines (GWTG) with acute myocardial infarction from October 2013 through December 2014 were included in the study (167 455 patients; 622 sites). We evaluated temporal trends in the prescription of P2Y12 inhibitors, and identified factors associated with ticagrelor use at discharge. Among patients discharged on ticagrelor and aspirin (21 262 patients), we evaluated the temporal trends and independent factors associated with high‐dose aspirin prescription at discharge. Ticagrelor prescription at discharge increased significantly from 12% to 16.7% (P<0.0001). Decreases in prasugrel and clopidogrel use at discharge (15.7%–13.9% and 54.2%–51.1%, respectively, P<0.0001) were also observed. Independent factors associated with preferential ticagrelor prescription at discharge over clopidogrel included younger age, white race, home ticagrelor use, invasive management, and in‐hospital re‐infarction and stroke (P<0.0001 for all), whereas older age, female sex, prior stroke, home ticagrelor use, and in‐hospital stroke (P<0.0001 for all) were associated with preferential ticagrelor prescription at discharge over prasugrel. High‐dose aspirin was used in 3.1% of patients discharged on ticagrelor. Independent factors associated with high‐dose aspirin prescription at discharge included home aspirin use, diabetes mellitus, previous myocardial infarction, previous coronary artery bypass graft, ST‐segment–elevation myocardial infarction, cardiogenic shock, and geographic region (P=0.01).ConclusionsOur contemporary analysis shows a modest but significant increase in the use of ticagrelor and a high rate of adherence to the use of low‐dose aspirin at discharge.

Contemporary Antiplatelet Therapy and Clinical Outcomes of Japanese Patients With Acute Myocardial Infarction ― Results From the Prospective Japan Acute Myocardial Infarction Registry (JAMIR) ―

“…21,22 Recently, national registries of ACS in the USA and European countries have demonstrated an increasing use of the potent P2Y12 inhibitors and their efficacy in clinical practice. [23][24][25][26] However, the benefits of potent P2Y12 inhibitors in the Asian population have not been clarified. The multicenter, double-blind, randomized PHILO trial compared the efficacy and safety of ticagrelor vs. clopidogrel in 801 patients with ACS in East Asian countries including Japan.…”

Effect of Medication Co-payment Vouchers on P2Y12 Inhibitor Use and Major Adverse Cardiovascular Events Among Patients With Myocardial Infarction

“…After data collection was complete, the balance of covariates between intervention and usual care groups was assessed using standardized differences. 19 Data on patient race were collected because prior studies suggested that patients of nonwhite race were less likely to be prescribed higherpotency P2Y 12 inhibitors 6 and that racial differences in medication nonadherence likely mediate disparities in cardiovascular morbidity and mortality 20 ; race was retrospectively abstracted from the medical record.…”

A meta‐analysis of efficacy and safety of genotype‐guided versus standard of care treatment strategies in selecting antiplatelet therapy in patients with acute coronary syndrome

“…We believe that this is unlikely to have significantly affected outcomes. Fourth, in the study by Sanchez‐Ramos et al, the standard arm had a higher use of clopidogrel (93%) compared to trends in P2Y12 inhibitor use in contemporary U.S. practices 3,4 . However, sensitivity analysis after excluding this study still showed similar results.…”

“…The standard components of DAPT include aspirin as well as a P2Y12 receptor inhibitor 1,2 . Clopidogrel, which remains the most commonly used P2Y12 inhibitor, is an irreversible platelet aggregation inhibitor of P2Y12 receptors, and requires hepatic conversion to an active metabolite via the cytochrome P450 enzymatic pathway 3‐6 . Due to genetic variation in the general population, which results in the loss of function of CYP2C19 genes, approximately 30% of the U.S. population have an inadequate antiplatelet response to clopidogrel, and are therefore at a potential risk for thrombotic complications (particularly stent thrombosis) 7‐9 .…”