Discharge of Acute Coronary Syndrome Patients on Sub-Optimal Dual Anti-Platelet Therapy: A Single Center Experience

To identify and quantify the reasons why acute coronary syndrome (ACS) patients undergoing stenting at University of New Mexico Hospital were prescribed sub-optimal dual antiplatelet therapy (DAPT) at discharge, and to identify practice patterns that could potentially lead to improved DAPT treatment for these patients.

We reviewed electronic medical records and cardiac catheterization records of 326 patients who underwent PCI at UNMH between January 1, 2021, and June 30, 2022 and identified 229 ACS patients who survived until discharge. Demographic and clinical characteristics relevant to P2Y₁₂ selection were obtained from a review of medical records. Pharmacists' notes that documented their efforts to get appropriate insurance coverage and reasons for discharge on clopidogrel rather than ticagrelor were reviewed. Patients discharged on aspirin and clopidogrel underwent review of medical records and cardiac catheterization lab records to determine if the discharge P2Y₁₂ drug was appropriate. Reasons for inappropriately discharge on clopidogrel were categorized as cost/insurance, patient preference, concern for daily adherence to a twice-daily medication, and on clopidogrel before PCI and not switched to ticagrelor afterward.

The 229 ACS patients included (38.0%, n = 87) appropriately discharged on ticagrelor/prasugrel, (27.5%, n = 63) appropriately discharged on clopidogrel, (32.8%, n = 75) inappropriately discharged on clopidogrel, and (1.7%, n = 4) not discharged on a P2Y₁₂ inhibitor. For patients inappropriately discharged on clopidogrel (n = 75), the most common reasons were cost or lack of insurance (n = 56) and clinical inertia (taking clopidogrel before PCI and maintained on it afterward) (n = 17). Inappropriate DAPT at discharge correlated with lack of insurance (90.5% compared to 39.7% in patients with insurance, P < 0.001) but not with ethnicity.

At the University of New Mexico, a safety-net hospital, increasing financially restricted access to ticagrelor could help up to 24.5% of ACS patients reduce their risk of ischemic events. For patients admitted on clopidogrel DAPT, upgrading to ticagrelor could reduce ischemic risk in 7.4% of ACS patients. Expanding healthcare insurance coverage might redue sub-optimal DAPT coverage.