The majority of U.S. STEMI patients are discharged with a potent P2Y12 inhibitor, but demographic and clinical factors among STEMI patients may influence which P2Y12 inhibitor is prescribed, according to a study published in Circulation: Cardiovascular Quality and Outcomes. The study is part of ACC's Research to Practice (R2P) initiative, which identifies impactful cardiovascular research and analyzes its implications for contemporary clinical practice using ACC's NCDR clinical registries.

Kamil F. Faridi, MD, et al., used data from ACC's Chest Pain – MI Registry to look at 169,505 STEMI patients between October 2013 and March 2017. The study's primary outcome was the choice of P2Y12 inhibitor (clopidogrel, ticagrelor or prasugrel) administered at the time of discharge following a STEMI hospitalization. The researchers also looked at one-year rates of myocardial infarction (MI), stroke and bleeding hospitalization in a subset of 9,655 patients age 65 and older enrolled in Medicare and for whom longitudinal claims data were available.

According to the results, the average age of patients was 61.3 years and 28% were women. Most patients (95.5%) underwent PCI at the time of STEMI, while 5.5% received thrombolytics and 2.1% underwent CABG. During the study period, use of ticagrelor increased from 18% to 44%, while prasugrel use decreased from 24.6% to 13.5% and clopidogrel use decreased from 57.4% to 42.6%. According to the authors, prior PCI was the strongest clinical predictor for ticagrelor and prasugrel use. Predictors of clopidogrel use included a lack of insurance, being a Medicare or Medicaid beneficiary, and having a higher risk of bleeding.

Among patients who received a potent P2Y12 inhibitor, there were significant hospital-level variations in use of ticagrelor vs. prasugrel. In the subset of Medicare patients, one-year all-cause mortality after discharge when stratified by hospital-level quartile of potent P2Y12 inhibitor use ranged from 7.6% in the lowest quartile to 8.5% in the highest quartile. Unadjusted one-year rates of MI, stroke and bleeding were similar across quartiles.

The researchers note that nearly one-half of U.S. STEMI patients are receiving ticagrelor and that demographic and clinical characteristics influence which P2Y12 inhibitor is prescribed. There is "substantial variation" in hospital use of ticagrelor and prasugrel, they add, concluding that "identifying specific barriers to accessing newer P2Y12 inhibitors may improve patient-centered decision-making in the management of STEMI patients."

Clinical Topics: Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Interventions and Vascular Medicine, Chronic Angina

Keywords: ST Elevation Myocardial Infarction, Purinergic P2Y Receptor Antagonists, Patient Discharge, Medicare, Medicaid, Percutaneous Coronary Intervention, Myocardial Infarction, Hemorrhage, Registries, National Cardiovascular Data Registries, Stroke, Chest Pain, Chest Pain MI Registry

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