De-escalation to Clopidogrel in AMI

Predictors of de-escalation of P2Y12 inhibitors to clopidogrel in patients with acute myocardial infarction treated with percutaneous coronary intervention.

Williams MU, et al. Cardiovasc Revasc Med. 2022:S1553-8389(22)00055-0.

Key Takeaway

• This retrospective study, the first study to detail the reasons for P2Y12 inhibitor de-escalation revealed that:
  • Patients with AMI treated with PCI were frequently de-escalated to clopidogrel prior to discharge following initial treatment with potent P2Y12 inhibitor
  • De-escalation was performed because of clinical/non-clinical factors and reasons were poorly documented by the clinicians, representing an area for improvement

Why This Matters

• In patients with ACS undergoing PCI, potent P2Y12 inhibitors ticagrelor and prasugrel have shown superior efficacy in reducing ischemic complications and stent thromboses vs clopidogrel, but with an increased bleeding risk.^*
• Patients treated with more potent P2Y12 inhibitors are often deescalated to clopidogrel; however, the reasons were not well defined in the existing literature or registries.

This study assessed the incidence and predictors of in-hospital de-escalation from a potent P2Y12 inhibitor to clopidogrel in a cohort of patients with AMI PCI.

Study Design

A retrospective study was conducted in two tertiary centers at USA using data obtained from the electronic health record and institutional NCDR CathPCI.

 

Patients included

• Consecutive patients who received ticagrelor or prasugrel loading dose for AMI PCI with a drug eluting stent between Jan 2015 and Mar 2019 who survived to discharge.

Analyses

• Patients de-escalated to clopidogrel were compared with those who remained on potent P2Y12 inhibitors through the time of discharge.

Data evaluated

• The risk of bleeding prediction for all patients were determined using the PRECISE-DAPT score.
• Manual chart review of all patients was performed to identify the documented reason(s) for P2Y12 de-escalation.

Key Results

Of the 1,818 included patients in the overall cohort, 1,146 (63%) patients underwent P2Y12 inhibitor de-escalation. (age = 65.1 ± 13.1 years; men = 69%)

Patient characteristics
Patients on medications	Ticagrelor = 92% Prasugrel = 8%
De-escalation group vs no de-escalation group
Age	65.1 years vs 63.7 years
Black race	6.0% vs 2.3%
Caucasian race	91% vs 94.6%
Diabetes prevalence	30.2% vs 37.2%
Private insurance	76.0% vs 83.2%
Bleeding risk	Similar in both groups
Pci complexity	Less complex PCI
Patient history†	A significant number of patients with history of myocardial infarction (20.4%), prior PCI (21.6%), were de-escalated (P <0.001)
The pre- and post-PCI hemoglobin, creatinine, and post-procedure bleeding events were similar in patients in both the groups No difference in de-escalation rates by clinical presentation, STEMI vs non- STEMI Patients receiving glycoprotein IIb/IIIa inhibitor were less likely to be de-escalated (P = 0.034)

Factors associated with de-escalation
Positive association
Older age	OR: 1.2 (95% CI: 1.08–1.34), P = 0.001
Negative association
Caucasian race	OR: 0.5 (95% CI: 0.33–0.77), P = 0.002
Prior mi	OR: 0.7 (95% CI: 0.5–0.97), P = 0.032
Bifurcation lesion intervention	OR: 0.71 (95% CI: 0.53–0.95), P = 0.019
Greater number of stents	OR: 0.82 (95% CI: 0.75–0.91), P = 0.0001
There was no change in rates of de-escalation over time during the study

Decision for de-escalation

• Not documented in 75.9% of patients

• Among those with a documented reason, the most common reasons were:

  • Medication cost = 14.9%

  • Bleeding risk = 6%

Limitations

• High number of patients de-escalated without a documented reason.
• Data on patient preferences were not collected.
• This study was not powered to analyze separately ticagrelor and prasugrel, and lesion subsets such as left main or chronic total occlusions.

^* Evidence suggest that tailoring antiplatelet regimens based on patient’s bleeding and ischemic risk may improve outcomes thana universally applied strategy
^†While prevalence of known coronary artery disease was high and they were at ischemic risk

MAT-BH-2300014/V1/JAN2023