Oral P2Y12 Inhibitor in Patients With ACS Undergoing PCI
Oral P2Y12 Inhibitor in Patients With ACS Undergoing PCI
Background P2Y12 inhibitor switching has appeared in clinical practice as a consequence of prasugrel and ticagrelor availability, apart from clopidogrel, for use in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).
Methods In the context of the GReek AntiPlatelet REgistry (GRAPE) we assessed the prevalence, predictive factors and short-term outcome of in-hospital P2Y12 inhibitor switching in 1794 ACS patients undergoing PCI.
Results Switching occurred in 636 (35.5%) patients of which in the form of clopidogrel to a novel agent, novel agent to clopidogrel and between prasugrel and ticagrelor in 574 (90.4%), 34 (5.3%) and 27 (4.3%) patients, respectively.
Presentation to non PCI-capable hospital, bivalirudin use, age ≥75 years (inverse predictor), and regional trends emerged as predictive factors of switching to a novel agent. At combined in-hospital and one-month follow-up, propensity matched pairs analysis showed no differences in major adverse cardiovascular (MACE) or bleeding events between switching from clopidogrel to a novel agent vs novel agent constant administration. More Bleeding Academic Research Consortium type 1, type 2 and any type events and fewer MACE were seen when switching from clopidogrel to a novel agent vs only clopidogrel administration (23.7%, 3.8%, 30.6%, 1.2% vs 8.9%, 1.2%, 12.0%, 3.8% with P < .001, P = .03, P < .001 and P = .03 respectively).
Conclusions In a real-life experience with contemporary antiplatelet treatment in ACS patients undergoing PCI, in-hospital switching represents common clinical practice. Clinical factors and regional practice differences seem to affect this strategy's choice, while switching to a novel agent may be associated with higher risk of bleeding.
An oral antiplatelet P2Y12 inhibitor administered on top of aspirin represents standard of care in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). With the availability of 3 oral P2Y12 inhibitors (clopidogrel, prasugrel and ticagrelor) having different efficacy and safety profile along with contraindications and special warnings and precautions for use, in-hospital switching of antiplatelet treatment has emerged in clinical practice. Furthermore, lack of a PCI indication at the early phase of hospitalization may also lead to selection of clopidogrel initially, with a novel P2Y12 inhibitor indication appearing at a later stage. Switching from clopidogrel to prasugrel or ticagrelor has been suggested as an alternative for clinical settings in which the novel agents have shown to be more beneficial compared with clopidogrel, while switching from the novel P2Y12 inhibitors to clopidogrel, should be considered for patients in whom the former are either contraindicated or special warnings and precautions for their use exist.
Data on switching antiplatelet treatment have been mostly obtained from small-sized pharmacodynamic studies. Switching from clopidogrel to prasugrel or from clopidogrel to ticagrelor was well tolerated with no major bleeding events reported. However, the clinical effect of switching on efficacy or safety in patients with ACS undergoing PCI has not been established. In the PLATO trial a significant part of patients (46%) randomised to ticagrelor had received clopidogrel at presentation and then switched to assigned treatment, with no specific safety concerns reported. Similarly, in the prasugrel treated cohort of the TRILOGY ACS trial, 96% of patients switched treatment following clopidogrel initial administration. No differential event rate was seen according to clopidogrel pretreatment strata.
So far, real-life data on P2Y12 inhibitor in-hospital switching are scarce and only in the form of preliminary reports. In the present study, in the context of the GReek AntiPlatelet REgistry (GRAPE) in patients with ACS undergoing PCI and with all the 3 oral P2Y12 inhibitors being available for clinical use, we investigated the prevalence, predictive factors and short-term outcome of in-hospital P2Y12 inhibitor switching.
Abstract and Introduction
Abstract
Background P2Y12 inhibitor switching has appeared in clinical practice as a consequence of prasugrel and ticagrelor availability, apart from clopidogrel, for use in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).
Methods In the context of the GReek AntiPlatelet REgistry (GRAPE) we assessed the prevalence, predictive factors and short-term outcome of in-hospital P2Y12 inhibitor switching in 1794 ACS patients undergoing PCI.
Results Switching occurred in 636 (35.5%) patients of which in the form of clopidogrel to a novel agent, novel agent to clopidogrel and between prasugrel and ticagrelor in 574 (90.4%), 34 (5.3%) and 27 (4.3%) patients, respectively.
Presentation to non PCI-capable hospital, bivalirudin use, age ≥75 years (inverse predictor), and regional trends emerged as predictive factors of switching to a novel agent. At combined in-hospital and one-month follow-up, propensity matched pairs analysis showed no differences in major adverse cardiovascular (MACE) or bleeding events between switching from clopidogrel to a novel agent vs novel agent constant administration. More Bleeding Academic Research Consortium type 1, type 2 and any type events and fewer MACE were seen when switching from clopidogrel to a novel agent vs only clopidogrel administration (23.7%, 3.8%, 30.6%, 1.2% vs 8.9%, 1.2%, 12.0%, 3.8% with P < .001, P = .03, P < .001 and P = .03 respectively).
Conclusions In a real-life experience with contemporary antiplatelet treatment in ACS patients undergoing PCI, in-hospital switching represents common clinical practice. Clinical factors and regional practice differences seem to affect this strategy's choice, while switching to a novel agent may be associated with higher risk of bleeding.
Introduction
An oral antiplatelet P2Y12 inhibitor administered on top of aspirin represents standard of care in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). With the availability of 3 oral P2Y12 inhibitors (clopidogrel, prasugrel and ticagrelor) having different efficacy and safety profile along with contraindications and special warnings and precautions for use, in-hospital switching of antiplatelet treatment has emerged in clinical practice. Furthermore, lack of a PCI indication at the early phase of hospitalization may also lead to selection of clopidogrel initially, with a novel P2Y12 inhibitor indication appearing at a later stage. Switching from clopidogrel to prasugrel or ticagrelor has been suggested as an alternative for clinical settings in which the novel agents have shown to be more beneficial compared with clopidogrel, while switching from the novel P2Y12 inhibitors to clopidogrel, should be considered for patients in whom the former are either contraindicated or special warnings and precautions for their use exist.
Data on switching antiplatelet treatment have been mostly obtained from small-sized pharmacodynamic studies. Switching from clopidogrel to prasugrel or from clopidogrel to ticagrelor was well tolerated with no major bleeding events reported. However, the clinical effect of switching on efficacy or safety in patients with ACS undergoing PCI has not been established. In the PLATO trial a significant part of patients (46%) randomised to ticagrelor had received clopidogrel at presentation and then switched to assigned treatment, with no specific safety concerns reported. Similarly, in the prasugrel treated cohort of the TRILOGY ACS trial, 96% of patients switched treatment following clopidogrel initial administration. No differential event rate was seen according to clopidogrel pretreatment strata.
So far, real-life data on P2Y12 inhibitor in-hospital switching are scarce and only in the form of preliminary reports. In the present study, in the context of the GReek AntiPlatelet REgistry (GRAPE) in patients with ACS undergoing PCI and with all the 3 oral P2Y12 inhibitors being available for clinical use, we investigated the prevalence, predictive factors and short-term outcome of in-hospital P2Y12 inhibitor switching.
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