Journal Wrap

Clopidogrel Used More Often Than Newer Antiplatelet Agents

The antiplatelet agent clopidogrel may be used more often than newer antiplatelet therapies ticagrelor and prasugrel following PCI procedures, according to a study published recently in the American Journal of Cardiology.

Using data from ACC's and Veradigm's PINNACLE Registry, Umair Khalid, MD, et al., evaluated patient characteristics and provider/practice factors associated with prescriptions for newer antiplatelet agents in patients who underwent PCI with a drug-eluting stent and received prescriptions for dual antiplatelet therapy. All patients received aspirin. The researchers assessed whether patients were prescribed clopidogrel, prasugrel or ticagrelor for the second antiplatelet agent and compared baseline characteristics among the three groups.


Of 26,710 patients, 21,024 (79%) received clopidogrel, 3,131 (12%) received prasugrel and 2,555 (11%) received ticagrelor. Patients who were more likely to be prescribed clopidogrel vs. prasugrel or ticagrelor included women, those older than 75 years, and those with a history of prior tobacco use or peripheral arterial disease, hypertension, diabetes, previous vascular complications, heart failure and stroke.

A larger percentage of patients with a history of prior myocardial infarction (MI) took prasugrel or ticagrelor vs. those without a previous MI. Between the newer agents, ticagrelor was more likely to be prescribed in patients age 75 or older with a history of MI and less likely to be prescribed to patients whose body mass index was higher than 25 kg/m2.

The researchers note their findings show that older patients were more likely to be prescribed clopidogrel than prasugrel or ticagrelor, suggesting that providers may be more comfortable prescribing clopidogrel than newer medications in high-risk elderly populations with increased bleeding risk. They conclude that ticagrelor and prasugrel were mostly prescribed per current guidelines and that clopidogrel was used far more often than the newer agents.

Khalid U, Bandeali S, Jones PG, et al. Am J Cardiol 2019;124:1807-12.


Intravascular Microaxial LVAD Associated With Higher Risk of In-Hospital Mortality, Bleeding

In patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) undergoing PCI, use of an intravascular microaxial left ventricular assist device (LVAD) (Impella; Abiomed) may be associated with higher rates of in-hospital adverse events compared with an intra-aortic balloon pump (IABP), according to a study published in the Journal of the American Medical Association.

Sanket Dhruva, MD, MHS, FACC, et al., examined data from ACC's CathPCI Registry and Chest Pain – MI Registry to assess mechanical circulatory support (MCS) device utilization from October 2015 to December 2017 among patients with AMI-CS undergoing PCI. Among the total of 28,304 AMI-CS patients, the mean age was 65 years, 33% were women, 81.3% had STEMI, and 43.3% had cardiac arrest.


Treatment was an IABP only in 8,471 (29.9%); an intravascular microaxial LVAD only in 1,768 (6.2%); other mechanical circulatory support or a combination of devices in 1,838 (6.5%); and medical therapy only in 16,227 (57.3%).

Results showed a significantly higher risk of in-hospital mortality with the intravascular microaxial LVAD vs. IABP (45% vs. 34.1%). The risk of in-hospital major bleeding was higher with the intravascular microaxial LVAD (31.3%) vs. IABP (16%). The differences were statistically significant "regardless of timing of device placement."

According to the researchers, the intravascular microaxial LVAD device "was associated with a higher risk of in-hospital mortality and major bleeding. They note the findings "highlight the need for additional data to guide optimal management" for AMI-CS patients and the role of MCS devices. "Further research may be needed to understand optimal device choice," they conclude.

In an accompanying editorial, Holger Thiele, MD, et al., write that the study provides "evidence to support a more restrictive use of these devices, and as based on current guidelines, only in selected patients with refractory cardiogenic shock."

Dhruva SS, Ross JS, Mortazavi BJ, et al. JAMA 2020;Feb 10:[Epub ahead of print].


Ticagrelor Use Increasing, With Hospital and Patient Variations

Use of the P2Y12 inhibitor ticagrelor has steadily increased since its 2011 approval by the U.S. Food and Drug Administration, with variations based on patient- and hospital-level characteristics, according to a study published in the International Journal of Cardiology.

Benjamin A. Rodwin, MD, et al., reviewed data from ACC's Chest Pain – MI Registry to describe trends in the use of the P2Y12 inhibitors clopidogrel, ticagrelor and prasugrel among 362,354 myocardial infarction (MI) patients treated at 801 hospitals from 2009 through 2017. The researchers looked at patient- and hospital-level characteristics with associated medication choice, compared patient case mix among hospitals with higher vs. lower uptake of ticagrelor, and examined variation in ticagrelor use among hospitals over time.


During the study period, overall use of ticagrelor increased from 6.1% to 33.7%, with corresponding decreases in use of clopidogrel (73.1% to 55.2%) and prasugrel (20.8% to 11.1%). Patients who were prescribed either prasugrel or ticagrelor were more likely to have private insurance and present with STEMI but were less likely to have a history of prior MI, diabetes, hypertension or dyslipidemia. Patients who presented with STEMI and who were white and received treatment in the northeastern U.S. were most likely to receive ticagrelor.

In addition, the researchers divided the hospitals into quartiles based on ticagrelor uptake. They found that facilities in the highest quartile had ticagrelor use rates of 29.4% to 88.4%, while rates in the lowest quartile ranged from 0% to 8.2%. Higher-uptake hospitals were more likely to be in the northeast and have lower annual volumes of STEMI and NSTEMI patients. Hospital-level rates of ticagrelor use at the time of discharge increased over time, from a median of 5% to 25%.

According to the researchers, the study shows a "rapid rise in the use of ticagrelor" and offers "important insight" for determining patient- and hospital-level characteristics associated with adoption of new treatments. They conclude that moving forward, their findings "could represent foundational research for future quality improvement initiatives aimed at incorporating the latest evidence into routine clinical practice."

Rodwin BA, Lu D, Giaimo A, et al. Int J Cardiol 2020;Jan 15:[Epub ahead of print].


Keywords: ACC Publications, Cardiology Magazine

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