Early Discontinuation of P2Y12 Antagonists and Adverse Clinical Events Post-Percutaneous Coronary Intervention: A Hospital and Primary Care Linked Cohort
29 October 2019
Daniel E. Harris , Arron Lacey, Ashley Akbari, Daniel R. Obaid, Dave A. Smith, Geraint H. Jenkins, James P. Barry, Mike B. Gravenor, and Julian P. Halcox
Journal of the American Heart Association. 2019;8:e012812
Background Early discontinuation of P2Y12 antagonists post–percutaneous coronary intervention may increase risk of stent thrombosis or nonstent recurrent myocardial infarction. Our aims were to (1) analyze the early discontinuation rate of P2Y12 antagonists post–percutaneous coronary intervention, (2) explore factors associated with early discontinuation, and (3) analyze the risk of major adverse cardiovascular events (death, acute coronary syndrome, revascularization, or stroke) associated with discontinuation from a prespecified prescribing instruction of 1 year.
Method and Results We studied 2090 patients (2011–2015) who were recommended for clopidogrel for 12 months (+aspirin) post–percutaneous coronary intervention within a retrospective observational population cohort. Relationships between clopidogrel discontinuation and major adverse cardiac events were evaluated over 18‐month follow‐up. Discontinuation of clopidogrel in the first 4 quarters was low at 1.1%, 2.6%, 3.7%, and 6.1%, respectively. Previous revascularization, previous ischemic stroke, and age >80 years were independent predictors of early discontinuation. In a time‐dependent multiple regression model, clopidogrel discontinuation and bleeding (hazard ratio=1.82 [1.01–3.30] and hazard ratio=5.30 [3.14–8.94], respectively) were independent predictors of major adverse cardiac events as were age <49 and ≥70 years (versus those aged 50–59 years), hypertension, chronic kidney disease stage 4+, previous revascularization, ischemic stroke, and thromboembolism. Furthermore, in those with both bleeding and clopidogrel discontinuation, hazard ratio for major adverse cardiac events was 9.34 (3.39–25.70).
Conclusions Discontinuation of clopidogrel is low in the first year post–percutaneous coronary intervention, where a clear discharge instruction to treat for 1 year is provided. Whereas this is reassuring from the population level, at an individual level discontinuation earlier than the intended duration is associated with an increased rate of adverse events, most notably in those with both bleeding and discontinuation.
What Is New? In this real‐world study following patients discharged post–percutaneous coronary intervention where the duration of dual antiplatelet therapy was known, discontinuation of P2Y12 antagonist therapy was low and much lower than reported in other studies.
Despite the low discontinuation rate, it was an important predictor of major adverse outcomes in this population, especially in those with concomitant bleeding.
What Are the Clinical Implications? Discontinuation of P2Y12 antagonist therapy earlier than intended is associated with an increased rate of adverse events, highlighting the importance of processes optimizing concordance with evidence‐based preventative therapy post–percutaneous coronary intervention.
Dr Arron Lacey
Lecturer in Health Data Science and Natural Language Processing
Dr Arron Lacey is a Lecturer in Health Data Science and Natural Language Processing at Swansea University Medical School. Arron’s areas of research include population health, bioinformatics,...
Associate Professor Population Data Science Research at Swansea University
Based at Swansea University since 2008, Ashley plays a substantive role in major research programmes & projects utilising population-scale data, predominantly using the SAIL Databank. Championing...