Based on current guidelines by the ACC and the American Heart Association, administering dual antiplatelet therapy as soon as possible for all eligible myocardial infarction (MI) is a recommended course of action regardless of a physician's impending revascularization strategy. Multiple randomized trials have shown that a P2Y12 antagonist, alongside aspirin, can significantly improve cardiovascular outcomes in ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) patients. Most of this data however, is based on the P2Y12 antagonist clopidogrel. Meanwhile, second-generation antagonists, such as prasugrel, have demonstrated a more rapid, potent and consistent antiplatelet effect than clopidogrel.

Additional Resources 2013 ACCF/AHA Guideline for the Management of STEMI 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NSTEMI

In a study published April 14 in Journal of the American Heart Association  , Matthew Sherwood, MD, Duke Clinical Research Institute, and his colleagues sought to understand the appropriateness of using either of these drugs and assess changes in antiplatelet management practices. They found that prasugrel use increased significantly from 2009-2012, jumping from three percent to 18 percent (five percent to 30 percent in STEMI and two to 10 percent in NSTEMI), as well as "concerning evidence of inappropriate use of prasugrel, and inadequate targeting of this more potent therapy to maximize the benefit/risk ratio."

Using data from the ACTION Registry-GWTG, researchers evaluated the patterns of P2Y12 antagonist use within 24 hours of admission in 100,228 STEMI patients and 158,492 NSTEMI patients in 548 hospitals between October 2009 and September 2012. From the resulting analysis the rates of early P2Y12 antagonist use were approximately 90 percent among STEMI and 57 percent among NSTEMI patients. In addition to the increase in prasugrel use, there was also an observed decrease in use of early but not discharge P2Y12 antagonist among NSTEMI patients. Despite being contraindicated, three percent of patients with prior stroke received prasugrel, and was used in 1.9 percent of patients 75 years or older and in 4.5 percent of patients with weight below 60 kg. In both STEMI and NSTEMI patients, prasugrel was most frequently used in patients at the lowest predicted risk for bleeding and mortality, and despite a lack of supporting evidence, was initiated before cardiac catheterization in 18 percent of NSTEMI patients.

Based on these findings, Sherwood and his colleagues conclude that there remains a substantial opportunity for systems to improve their risk stratification of MI patients and to guide appropriate targeting of potent antiplatelet therapy to those most likely to benefit, preventing inappropriate use in patients with contraindications or at high risk of bleeding.

Keywords: Odds Ratio, Registries, Myocardial Infarction, Stroke, Thiophenes, Cardiac Catheterization, Ticlopidine, Piperazines, ACTION Registry, National Cardiovascular Data Registries

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