Antiplatelet Therapy Changes for Patients With Myocardial Infarction With Recurrent Ischemic Events: Insights Into
Alexander C Fanaroff1,2, Lisa A Kaltenbach2, Eric D Peterson3,2
1Division of Cardiology, Duke University, Durham, NC alexander.fanaroff@duke.edu.
Insights
Few patients with recurrent myocardial infarction (MI) events intensified P2Y12 inhibitor therapy. This study highlights the need for clear guidance on antiplatelet management following recurrent ischemic events after MI.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Current guidelines recommend 1-year P2Y12 inhibitor therapy post-myocardial infarction (MI).
- Limited guidance exists for managing antiplatelet therapy in patients experiencing recurrent ischemic events during this period.
- The TRANSLATE-ACS study investigated treatment patterns and outcomes after acute coronary syndrome.
Purpose of the Study:
- To examine changes in P2Y12 inhibitor therapy among patients with recurrent ischemic events within the first year after MI.
- To identify factors associated with P2Y12 inhibitor intensification (switching from clopidogrel to prasugrel or ticagrelor).
Main Methods:
- Analysis of 12,365 patients from the TRANSLATE-ACS study treated with percutaneous coronary intervention for MI.
- Examination of P2Y12 inhibitor use changes in patients experiencing recurrent MI, stent thrombosis, or unplanned revascularization.
- Modeling factors associated with P2Y12 inhibitor intensification.
Main Results:
- 11% of patients (1414) experienced recurrent ischemic events within the first year post-MI.
- Only 9.3% of clopidogrel-treated patients with recurrent events underwent P2Y12 inhibitor intensification.
- Recurrent MI and stent thrombosis were strong predictors for intensification, yet only 40% with stent thrombosis and 14% with recurrent MI were intensified.
Conclusions:
- A small proportion of patients with recurrent ischemic events after MI, including those with stent thrombosis, escalated to more potent P2Y12 inhibitors.
- There is a need for specific clinical guidance on managing antiplatelet therapy for patients with recurrent ischemic events, especially when events occur closely together.
Background:
Guidelines recommend P2Y12 inhibitor therapy for 1 year after myocardial infarction (MI), yet little guidance is provided on antiplatelet management for patients with recurrent ischemic events during that year. We describe changes in P2Y12 inhibitor type among patients with recurrent ischemic events in the first year after MI.
Methods And Results:
The TRANSLATE-ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study enrolled 12 365 patients with MI treated with percutaneous coronary intervention. We examined whether P2Y12 inhibitor choice changed among patients with recurrent MI, stent thrombosis, and/or unplanned revascularization during the first year after MI, and modeled factors associated with P2Y12 inhibitor intensification (changing clopidogrel to prasugrel or ticagrelor). In the first year after MI, 1414 patients (11%) had a total of 1740 recurrent ischemic events (771 recurrent MIs, 969 unplanned revascularizations, and 165 stent thromboses). Median time to the first recurrent ischemic event was 154 days (25th-75th percentiles, 55-287 days). Of those with recurrent ischemic events, 101 of 1092 (9.3%) occurring in clopidogrel-treated patients led to P2Y12 inhibitor intensification. Recurrent events involving stent thrombosis or MI were the strongest factors associated with P2Y12 inhibitor intensification, yet only 40% of patients with stent thrombosis and 14% of patients with recurrent MI had P2Y12 inhibitor intensification. Increasing age and longer time from the index MI were associated with lower likelihood for intensification.
Conclusions:
Few patients after MI with a recurrent ischemic event who were taking clopidogrel switched to a more potent P2Y12 inhibitor, even after stent thrombosis events. Specific guidance is needed for patients who have recurrent ischemic events, particularly when closely spaced.
Clinical Trial Registration:
URL: https://www.clinicaltrials.gov. Unique identifier: NCT01088503.
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