Effect of de-escalated P2Y12 inhibitor switching in dual antiplatelet therapy (DAPT)

Main Takeaway

A real-word study of Taiwanese patients with AMI undergoing PCI

• Showed a comparable 1-year cardiovascular outcome with standard ticagrelor treatment 3 months after the event of AMI
• Didn’t report statistically significant differences in:
  • Hazard risk of death
  • AMI admission
  • Major adverse
  • Cardiovascular events (MACE)
• Didn’t show a difference in the risk of bleeding, including major or clinically relevant non-major bleeding

Why This Matters

• Bleeding risks could be reduced P2Y12 inhibitor de-escalation approach is considered by physicians to reduce additional bleeding risks
• Current studies are not enough Despite recent clinical studies, there’s limited and conflicting evidence on de-escalation strategies. This study aimed to assess the effect of de-escalated P2Y12 inhibitor switching in DAPT on MACE in patients with AMI undergoing PCI;

Study Design

This retrospective and population-based cohort study utilized data from the Taiwan’s National Health Insurance Research Database (NHIRD).

Key Inclusion Criteria:

• Patients who were hospitalized with a primary diagnosis of AMI

Key Exclusion Criteria:

• Patients aged <18 years, without identification of sex, or Taiwanese citizenship
• Patients not on heparin or antiplatelet therapy, or were only on aspirin therapy, or
• received antiplatelet agents other than ticagrelor at index of AMI
• Patients who had a coronary artery bypass graft
• Death of the patient within 3 months after the index date of AMI

Key Outcomes:

• Death, AMI readmission, and MACE within one year during the follow-up period

Key Results

Number Of Participants

• 10,100 patients were included (de-escalated DAPT group: n = 1,901; unchanged DAPT: n = 8,199)

Incidence Rates And Adjusted Hazard Ratio

• All-cause death (unchanged vs de-escalated DAPT group): Incidence = 2.42 (95% confidence interval [CI]: 2.02–2.90) vs 2.89 (95% CI: 2.05–3.91); adjusted HR = 1.20 (95% CI: 0.83–1.73; P = 0.336)
• AMI hospitalization (unchanged vs de-escalated DAPT group): Incidence = 3.28 (95% CI: 2.81–3.83) vs 3.68 (95% CI: 2.75–4.88); adjusted HR = 1.12 (95% CI: 0.80–1.56; P = 0.509)
• MACE (unchanged vs de-escalated DAPT group): Incidence = 4.72 (95% CI: 4.13–5.36) vs 4.91 (95% CI: 3.80–6.26); adjusted HR = 1.04 (95% CI: 0.78–1.39; P = 0.766)
• Major bleeding (unchanged vs de-escalated DAPT group): Incidence = 2.36 (95% CI: 1.95–2.82) vs 2.12 (95% CI: 1.41–3.01); adjusted HR = 0.92 (95% CI: 0.61–1.37; P = 0.669)

Limitations

• Patient information such as risk behaviors, diet, and physical activities are not available in the NHIRD.
• Hidden bias of medication selection was introduced as the study data was sourced from an administrative database.
• Missing clinical information, such as the severity of AMI at admission, might have induced non-differential misclassification bias.
• Study results might not be generalizable to other populations, as only Taiwanese patients were included in the analysis.