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Bleeding risk and P2Y12 inhibitors in all-comer patients with ST-segment elevation myocardial infarction treated with
Mia Ravn Jacobsen1, Reza Jabbari1, Thomas Engstrøm1
1Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark.
Insights
A significant portion of ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) are at high bleeding risk (HBR). These HBR patients often receive potent P2Y12 inhibitors, suggesting a prioritization of ischemic risk over bleeding risk.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- ST-segment elevation myocardial infarction (STEMI) patients require dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI).
- Assessing bleeding risk is crucial for optimizing DAPT, especially in high bleeding risk (HBR) populations.
- The PRECISE-DAPT score is a validated tool for predicting bleeding complications in patients on DAPT.
Purpose of the Study:
- To characterize STEMI patients at HBR using the PRECISE-DAPT score.
- To examine the utilization of P2Y12 inhibitors in HBR STEMI patients.
- To assess the association between P2Y12 inhibitor choice and the risk of major adverse cardiovascular events (MACE) and bleeding.
Main Methods:
- A single-centre cohort study of 6179 consecutive STEMI patients undergoing PCI.
- Utilized nationwide registries for comprehensive data on diagnoses, medications, and vital status.
- Calculated PRECISE-DAPT scores for risk stratification and analyzed P2Y12 inhibitor use and clinical outcomes.
Main Results:
- 33.0% of STEMI patients with available PRECISE-DAPT scores were identified as HBR.
- HBR patients were older, more frequently female, and had more comorbidities.
- One-year incidence of major bleeding and MACE was significantly higher in HBR patients (8.7% and 36.8% vs. 2.1% and 8.3%).
- HBR patients were more likely treated with ticagrelor or prasugrel compared to clopidogrel.
- Ticagrelor/prasugrel use was associated with lower MACE risk without increasing major bleeding compared to clopidogrel.
Conclusions:
- Approximately one-third of STEMI patients treated with PCI are at HBR.
- HBR patients are frequently treated with more potent P2Y12 inhibitors (ticagrelor/prasugrel) over clopidogrel.
- This treatment pattern suggests a potential emphasis on managing ischemic risk over bleeding risk in HBR STEMI patients.
Aims:
To characterize and follow patients with ST-segment elevation myocardial infarction (STEMI) at high bleeding risk (HBR) according to the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score, and to examine the use of P2Y12 inhibitors and the subsequent risk of major adverse cardiovascular events (MACE) and bleeding.
Methods And Results:
This single-centre cohort study included 6179 consecutive STEMI patients who underwent percutaneous coronary intervention (PCI) at Copenhagen University Hospital, Rigshospitalet, between 2009 and 2016. Individual linkage to nationwide registries was conducted to obtain information on diagnoses, claimed drugs, and vital status. Of the 5532 (89.5%) patients with available PRECISE-DAPT scores, 33.0% were at HBR and more often elderly and female with more comorbidities than non-HBR patients. One-year cumulative incidence rates per 100 person-years were 8.7 and 2.1 for major bleeding and 36.8 and 8.3 for MACE in HBR and non-HBR patients, respectively. Among the 4749 (85.8%) patients who survived and collected a P2Y12 inhibitor ≤7 days from discharge, 68.2% of HBR patients were treated with ticagrelor or prasugrel and 31.8% with clopidogrel, while 18.2% non-HBR patients were treated with clopidogrel. Adherence was high for all (>75% days coverage). The risk of MACE was lower in ticagrelor- and prasugrel-treated patients than in clopidogrel-treated patients without differences in major bleeding.
Conclusion:
One-third of PCI-treated all-comer patients with STEMI were at HBR according to the PRECISE-DAPT score and were more often treated with potent P2Y12 inhibitors instead of clopidogrel. Thus, ischaemic risk may be weighted over bleeding risk in STEMI patients at HBR.
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