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APpropriateness Assessment in Antiplatelet THerapY (APATHY) registry: Insight from current clinical practice
Nazario Carrabba1, Benedetta Bellandi1, Guido Parodi1
1Cardiovascular and Thoracic Department of Careggi Hospital, Florence, Italy.
Insights
Antiplatelet strategies for acute coronary syndrome (ACS) often deviate from guidelines. While clopidogrel is common, newer agents are underutilized, with switching based on high residual platelet reactivity (HRPR).
Area of Science:
- Cardiology
- Pharmacology
- Clinical Practice
Background:
- A gap exists between guideline recommendations and current antiplatelet strategies for acute coronary syndrome (ACS).
- Evaluation of antiplatelet strategy appropriateness in a tertiary care setting is crucial.
Purpose of the Study:
- To assess the appropriateness of antiplatelet therapies used in patients with ACS undergoing percutaneous coronary intervention.
- To identify factors influencing the prescription of third-generation P2Y12 inhibitors.
Main Methods:
- Retrospective analysis of 430 ACS cases treated between January and June 2014.
- Review of antiplatelet regimens, including aspirin, clopidogrel, prasugrel, and ticagrelor.
- Assessment of inappropriate use and reasons for switching antiplatelet agents, including high residual platelet reactivity (HRPR) testing.
Main Results:
- Clopidogrel with aspirin was the most frequent antiplatelet therapy (52%).
- Third-generation P2Y12 inhibitors (prasugrel and ticagrelor) were prescribed in 25.5% and 22.5% of cases, respectively.
- High residual platelet reactivity (HRPR) was the strongest predictor for prescribing third-generation P2Y12 inhibitors (OR 5.473), while older age and cardiologist behavior influenced prescription rates.
Conclusions:
- Clopidogrel remains the predominant P2Y12 inhibitor for ACS, with lower-than-expected use of third-generation agents.
- Switching antiplatelet therapy was often driven by HRPR, indicating a need for improved guideline adherence.
- Enhanced efforts are required to align clinical practice with current evidence-based recommendations for ACS management.
Background:
In clinical practice there is a gap between guidelines recommendation and antiplatelet strategies used for acute coronary syndrome (ACS). We sought to evaluate appropriateness of antiplatelet strategies employed in a tertiary center.
Methods And Results:
From January to June 2014, 430 ACS were treated with percutaneous coronary intervention by 3 groups of interventional cardiologists. Aspirin and clopidogrel (52%) were the most commonly used antiplatelet therapies, being prasugrel associated with aspirin in 110 (25.5%) and ticagrelor in 97 (22.5%) ACS. Inappropriate use of prasugrel (Tia/Ictus) was found in 2 (1.8%) patients and not recommended use (>75years, without diabetes or previous myocardial infarction) in 11 (10%). Not recommended use of ticagrelor (plus warfarin) was found in 4 (4.4%). Switching from clopidogrel to prasugrel occurred in 29% [28 showing high residual platelet reactivity (HRPR: ADP 10μmol>70%), and 4 left main stenting], while from clopidogrel to ticagrelor occurred in 13.4% (all showing HRPR, but 1). The most powerful predictor for prescription of 3rd generation P2Y12 inhibitors was the HRPR (OR 5.473, 95%CI 2.41-12.43, p<0.0001), whereas the behavior of attending cardiologist (HR 0.674, 95%CI 0.573-0.847, p=0.001) and the older age reduced the probability of receiving it (OR0.963, 95%CI 0.943-0.984, p=0.001).
Conclusions:
Clopidogrel remained the most common P2Y12 inhibitor employed for ACS. Third generation P2Y12 inhibitor prescription was lower than the one expected by guidelines recommendations, and the switching was largely based on clopidogrel HRPR. These findings suggest the need for a greater effort to improve adherence of cardiology community to current guidelines.
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