Implications of the PEGASUS-TIMI 54 trial for US clinical practice

This study aims to determine the proportion of real-world patients with myocardial infarction (MI) who would have been eligible for the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial Infarction 54) trial, to characterise their current use of P2Y₁₂ inhibitors and to explore the estimated costs and ischaemic event consequences of increasing P2Y₁₂ inhibitor use among these patients.

In the US national ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines), we identified 273 328 patients with MI and determined the proportion that would have met the eligibility criteria for the PEGASUS trial. We described longitudinal P2Y₁₂ inhibitor use among patients eligible for PEGASUS and estimated the cost and ischaemic consequences of increasing P2Y₁₂ use among eligible patients.

A total of 112 222 (41.1%) patients with MI in ACTION Registry-GWTG met eligibility for the PEGASUS trial. Among 83 871 eligible patients with pharmacy claims data, 23 042 (27.5%) were on a P2Y₁₂ inhibitor at 1 year, 9661 (11.5%) at 2 years and 5246 (6.3%) at 3 years, with the majority (79.2%) of these patients on clopidogrel. The use of ticagrelor in eligible patients not yet on a P2Y₁₂ inhibitor at 1 year post-MI would cost an estimated US$885 000 per MI, stroke or cardiovascular death averted over a 3-year time horizon, while the use of clopidogrel would cost an estimated US$19 800 per ischaemic event averted.

In contemporary clinical practice, a minority of patients are on a P2Y₁₂ inhibitor beyond 1-year post-MI. Applying PEGASUS trial findings to clinical practice would result in a large increase in P2Y₁₂ inhibitor use, with a cost per ischaemic event averted that is strongly influenced by the choice of therapy.