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Tailoring Antiplatelet Therapy Intensity to Ischemic and Bleeding Risk
Usman Baber1, Daniel E Leisman1, David J Cohen2
1Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (U.B., D.E.L., G.D., A.K., S.S., R.M.).
Circulation. Cardiovascular Quality and Outcomes
|January 5, 2019
Summary
Balancing ischemic and bleeding risk is crucial for patients undergoing percutaneous coronary intervention. Tailoring antiplatelet therapy (ticagrelor/prasugrel vs. clopidogrel) to individual patient risk profiles can optimize outcomes and potentially reduce costs.
Area of Science:
- Cardiology
- Pharmacology
- Health Economics
Background:
- Balancing ischemic and bleeding risk is a critical, evolving challenge in managing patients after percutaneous coronary intervention (PCI).
- Current antiplatelet therapy strategies require careful consideration of individual patient risk profiles to optimize clinical outcomes.
Purpose of the Study:
- To simulate the impact of ticagrelor or prasugrel versus clopidogrel on adverse ischemic and bleeding events and associated costs.
- To evaluate how tailoring antiplatelet therapy intensity based on patient-specific ischemic and bleeding risk levels affects health utility and economic outcomes.
Main Methods:
- Utilized the validated PARIS risk score to estimate 1-year ischemic (myocardial infarction, stent thrombosis) and bleeding (BARC 3/5) event rates in 1497 patients post-PCI with drug-eluting stents.
- Applied treatment effects from randomized trials to simulate event rates with ticagrelor/prasugrel vs. clopidogrel, incorporating National Inpatient Sample data for cost estimations.
- Calculated net costs and quality-of-life-weighted event rates under various drug pricing scenarios to compare risk-tailored therapy with standard clopidogrel treatment.
Main Results:
- One-year ischemic event rates were 12.6, 24.1, and 66.1 per 1000 person-years for low, intermediate, and high ischemic risk, respectively.
- Corresponding bleeding event rates were 11.0, 23.9, and 66.2 per 1000 person-years for low, intermediate, and high bleeding risk.
- Ticagrelor/prasugrel favored utility-weighted events when ischemic risk matched or exceeded bleeding risk; clopidogrel was favored when bleeding risk was higher. Costs were sensitive to drug pricing, with risk-tailored therapy becoming cost-saving as generic market share increased.
Conclusions:
- Tailoring antiplatelet therapy intensity to individual patient risk profiles after PCI may enhance health utility.
- This personalized approach has the potential to generate significant cost savings within the first year post-PCI.
- Risk stratification is essential for optimizing antiplatelet treatment strategies in patients undergoing percutaneous coronary intervention.
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