PATTERNS OF ADP RECEPTOR INHIBITOR USE DURING THE INDEX HOSPITALIZATION IN PATIENTS WITH MYOCARDIAL INFARCTION UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: INSIGHTS FROM THE CANADIAN OBSERVATIONAL ANTIPLATELET STUDY (COAPT)

Contemporary use of guideline-based higher potency P2Y12 receptor inhibitor therapy in patients with moderate-to-high risk non-ST-segment elevation myocardial infarction: Results from the Canadian ACS reflective II cross-sectional study

Background

After myocardial infarction, guidelines recommend higher‐potency P2Y12 receptor inhibitors, namely ticagrelor and prasugrel, over clopidogrel.

Hypothesis

We aimed to determine the contemporary use of higher‐potency antiplatelet therapy in Canadian patients with non‐ST‐elevation myocardial infarction (NSTEMI).

Methods

A total of 684 moderate‐to‐high risk NSTEMI patients were enrolled in the prospective Canadian ACS Reflective II registry at 12 Canadian hospitals and three clinics in five provinces between July 2016 and May 2018. Multivariable logistic regression modeling was performed to assess factors independently associated with higher‐potency P2Y12 receptor inhibitor use at discharge.

Results

At hospital discharge, 78.3% of patients were treated with a P2Y12 receptor inhibitor. Among patients discharged on a P2Y12 receptor inhibitor, use of higher‐potency P2Y12 receptor inhibitor was 61.4%. After adjustment, treatment in‐hospital with PCI (OR 4.48, 95%CI 3.34–6.03, p < .0001) was most strongly associated with higher use of higher‐potency P2Y12 receptor inhibitor, while oral anticoagulant use at discharge (OR 0.03, 95%CI 0.01–0.12, p < .0001), and atrial fibrillation (OR 0.40, 95%CI 0.17–0.98, p = .046) were most strongly associated with lower use of higher‐potency P2Y12 receptor inhibitor. Use of higher‐potency P2Y12 receptor inhibitor varied across provinces (range, 21.6%–78.9%).

Discussion

In contemporary Canadian practice, approximately 60% of moderate‐to‐high risk NSTEMI patients discharged on a P2Y12 receptor inhibitor are treated with a higher‐potency P2Y12 receptor inhibitor. In addition to factors that increase risk of bleeding, interprovincial differences in practice patterns were associated with use of higher‐potency P2Y12 receptor inhibitor at discharge. Opportunities remain for further optimization of evidence‐based, guideline‐recommended antiplatelet therapy use.

Secondary Prevention Beyond Hospital Discharge for Acute Coronary Syndrome: Evidence-Based Recommendations

In the past 3 decades, a better understanding of the pathophysiology of cardiovascular disease has resulted in innovations in the treatment and prevention of its clinical manifestations such as death, myocardial infarction, or stroke. After an acute coronary syndrome there are short- and long-term risks of subsequent cardiovascular events. This leads to opportunities to initiate strategies to reduce complications resulting from myocardial injury (cardiac protection) and to prevent recurrent acute coronary events (vascular protection). The results from clinical trials inform best practice and guidelines for patient management. Despite clear and consistent guidelines, an important number of patients are not receiving these treatments. Moreover, many others do not receive treatment that follows the strategy proven in the clinical trial and this is associated with a significant loss of opportunities to improve outcomes. The Canadian Heart Research Centre has therefore assembled a panel of experts to provide a review of available data and distill it to specific evidence-based recommendations that can be used by specialists and primary care physicians as a platform for secondary prevention. The therapeutic recommendations are conveniently divided into vascular protection (dual antiplatelet therapy, lipid-lowering, and renin angiotensin system inhibition) which should be considered in all patients; cardiac protection (addition of β-blocker therapy) in patients with left ventricular dysfunction including consideration for management of heart failure; and continuing management of risk factors and comorbid conditions on the basis of the specific patient profile. These recommendations are intended as a decision support tool and a quick reference for Canadian physicians.