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Adjustment of Antiplatelet Therapy in Patients With Myocardial Infarction Treated Without Revascularization: A
Nicolas Dostie1,2, Arman Sarshoghi1,3, Alexis Doucet1
1Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.
Insights
Postdischarge antiplatelet therapy for myocardial infarction (MI) patients managed without revascularization is varied. Dual antiplatelet therapy (DAPT) for 12 months is common, but strategies differ based on MI cause.
Area of Science:
- Cardiology
- Internal Medicine
- Pharmacology
Background:
- A significant number of myocardial infarction (MI) patients are treated medically without revascularization.
- Optimal antiplatelet strategies for this population remain unevaluated by randomized controlled trials.
- Practice patterns for antiplatelet therapy (APT) in medically managed MI patients are likely inconsistent.
Purpose of the Study:
- To investigate and describe postdischarge antiplatelet therapy (APT) practice patterns.
- To analyze prescribing trends in patients hospitalized for MI and managed without revascularization.
Main Methods:
- Retrospective cohort study at the Montreal Heart Institute (July 2020-July 2023).
- Inclusion criteria: patients aged ≥18 years hospitalized for MI and discharged without revascularization.
- Data collected on discharge antiplatelet patterns.
Main Results:
- 365 patients included; 42.7% were women (median age: 71.4 years).
- Reasons for non-revascularization included MI without obstructive coronary artery disease (38%), no angiography (32%), and severe/small branch disease (26%).
- At discharge: 41.9% received dual APT (DAPT), 38.4% single APT, 19.7% no antiplatelet agent. Clopidogrel-aspirin was the most common DAPT (34.0%), aspirin monotherapy most common (25.8%). DAPT duration was 12 months in 91.5% of cases. Strategies varied by MI etiology.
Conclusions:
- Postdischarge antiplatelet strategies for medically managed MI patients are heterogeneous.
- Dual antiplatelet therapy (DAPT) for 12 months appears to be a preferred strategy.
- Variability highlights clinical equipoise in this understudied patient group.
Background:
Although a substantial proportion of patients with myocardial infarction (MI) are treated without revascularization, no randomized controlled trial has evaluated the optimal antiplatelet strategy in this vulnerable population and practice patterns may be heterogeneous. This study aims to describe postdischarge antiplatelet therapy (APT) practice patterns in medically managed patients with MI.
Methods:
A retrospective cohort study was conducted at the Montreal Heart Institute (July 31, 2020-July 31, 2023). Patients aged ≥18 years hospitalized for MI and discharged without revascularization were included, and discharge antiplatelet patterns were documented.
Results:
A total of 365 patients were included, comprising 156 women (42.7%) (median age: 71.4 years [interquartile range: 61-83]). Reasons for being treated without revascularization include MI without obstructive coronary artery disease (n=139; 38%), no angiography performed (n=118; 32%), severe disease not amenable to revascularization (n=71; 20%), small branch disease (n=21; 6%), and spontaneous coronary dissection (n=16; 4%). At discharge, 41.9% (n=153) received dual APT (DAPT), 38.4% (n=140) received single APT, and 19.7% (n=72) received no antiplatelet agent. The most common DAPT regimen prescribed was clopidogrel-acetylsalicylic acid (aspirin) (34.0%; n=124), and the most frequently prescribed antiplatelet monotherapy was aspirin (25.8%; n=94). Among patients treated with DAPT, duration of prescription was 12 months in 91.5% of cases. Postdischarge antiplatelet strategy varied depending on the underlying MI etiology.
Conclusion:
Postdischarge antiplatelet strategies prescribed in patients with an MI treated without revascularization are heterogeneous, whereas the preferred strategy is DAPT for 12 months. This variability reflects current clinical equipoise in this understudied population.
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