According to a recent registry study published in JAHA, there is an increase in the use of ticagrelor in hospital and at discharge, with simultaneous decrease in the use of clopidogrel and prasugrel, in patients with acute myocardial infarction (AMI).
Dual antiplatelet therapy is the main therapeutic strategy in patients presenting with AMI. Ticagrelor is the first oral reversible P2Y12 receptor antagonist. PLATO trial showed that the use of ticagrelor significantly reduced the composite primary end point of vascular death, myocardial infarction, and stroke, without a significant increase in major bleeding, when compared with clopidogrel. However there was a higher rate of non–CABG-related major bleeding in the ticagrelor group as compared with clopidogrel group according to the study criteria (4.5% vs. 3.8%, P=0.03) and the TIMI criteria (2.8% vs. 2.2%, P=0.03).
Ticagrelor is currently approved by the US Food and Drug Administration (FDA) for patients with AMI. Previously there was an FDA warning stating that the use of high dose aspirin (>100 mg daily) decreased the effectiveness of ticagrelor and should be avoided. Subsequently, the 2016 ACC/AHA guidelines recommended the use of ticagrelor in preference to clopidogrel in patients with non-ST-elevation myocardial infarction (NSTMI) and stated the optimal maintenance dose of aspirin to be 81 mg daily in all patients receiving ticagrelor. However, there was no data available showing the contemporary dosing pattern of aspirin at discharge in patients treated with ticagrelor.
To address this Dr. Sukhdeep and colleagues conducted an observational study from the ACTION Registry GWTG (Get With The Guidelines) database to evaluate the temporal trends of ticagrelor in patients with post-MI along with dosing pattern of aspirin in patients receiving ticagrelor. They included 167,455 patients presenting with acute MI across the United States from October 2013 through December 2014. The final study population for analyzing discharge aspirin dose included 21,262 patients receiving ticagrelor at discharge.
P2Y12 inhibitors were prescribed in 68.5% of AMI patients within 24 hours of admission (early) and 82% of patients at discharge. Early ticagrelor use significantly increased during the process from 11.8% to 16.4% (STEMI 19.6%–27.6%; NSTEMI 6.8%–9.5%; P<0.0001 for all). Similarly, there was a significant increase in ticagrelor prescription at discharge from 12% to 16.7% (STEMI 17.5%–24.6%; NSTEMI 8.7%– 11.9%; P<0.0001 for both comparison). A concomitant decrease in the early use and the prescription of other P2Y12 inhibitors was also observed over this period (13.3% to 11.9%; 15.7%–13.9% for prasugrel, 43.4% to 39.5%; 54.2%–51.1% for clopidogrel, respectively).
Younger age, white race, private insurance, home ticagrelor use, invasive management and in-hospital re-infarction, stroke (P<0.0001 for all), and cardiogenic shock (P=0.001) were all independent factors related to preferential ticagrelor prescription at discharge over clopidogrel. However, prior cerebrovascular accident, atrial fibrillation, and coronary artery bypass graft surgery favoured clopidogrel prescription. On the other hand ,independent factors associated with ticagrelor prescription over prasugrel included older age, female sex, prior stroke, home ticagrelor use, in-hospital stroke (P<0.001 for all), and cardiogenic shock (P=0.001), whereas prior diabetes mellitus (P<0.001) and home prasugrel use (P<0.0001) were associated with prasugrel prescription.
To conclude, this registry study was a large and contemporary national data included patients with AMI showed a modest increase in the use of ticagrelor early hospitalization period and at discharge during the process, especially in patients presenting with STEMI. In addition, the authors noted a very high rate of adherence to the use of low-dose aspirin at discharge in AMI patients receiving ticagrelor. Finally, they also emphasised the crucial role of the clinical and demographic factors in the contemporary prescription patterns of aspirin dose at discharge in these patients.
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