Frequency and Practice Level Variation in Inappropriate and Non-Recommended Prasugrel Prescribing: Insights From the NCDR® PINNACLE Registry

Study Questions:

What is the frequency and practice-level variation in inappropriate and nonrecommended prasugrel prescribing in a national registry?


This was an analysis of data collected between 2009 and 2013 in the PINNACLE registry, a national, prospective, quality-improvement database. The authors evaluated the frequency of inappropriate or nonrecommended prasugrel prescribing; in PINNACLE, data were collected at the point of care for all outpatients with coronary artery disease, heart failure, atrial fibrillation, and hypertension. Inappropriate prasugrel prescription was defined as use in patients with documented history of stroke or transient ischemic attack (TIA). Nonrecommended treatment was defined as prasugrel use in patients ≥75 years of age. The authors also examined the use of prasugrel in patients receiving aspirin and warfarin concomitantly.


Of 27,533 patients receiving prasugrel, 3,824 patients (13.9%) had an inappropriate and 1,210 patients (4.4%) had a nonrecommended indication. Patients receiving an inappropriate prescription had a higher prevalence of comorbidities. A total of 4,248 (15.4%) patients received “triple therapy” with aspirin, warfarin, and prasugrel (the efficacy and safety of such triple therapy has not been established).


The authors concluded that nearly one in every five patients in the PINNACLE registry were receiving prasugrel for an inappropriate or a nonrecommended indication.


In appropriately selected patients, prasugrel compared to clopidogrel significantly decreases cardiovascular death, myocardial infarction, and stroke. However, prasugrel is associated with increased bleeding in patients with a history of previous stroke or TIA, and it is not associated with benefit in patients ≥75 years of age. Furthermore, the efficacy of ‘triple therapy’ with prasugrel given concomitantly with warfarin and aspirin has not been established, yet 15.4% of patients in this study were receiving such treatment. The findings of this analysis are important and should draw attention to the inappropriate/nonrecommended prescription of prasugrel; future efforts should focus on mechanisms through which to improve the evidence-based use of prasugrel.

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