Outcomes According to Cardiac Catheterization Referral and Clopidogrel Use Among Medicare Patients With Non-ST-Segment Elevation Myocardial Infarction Discharged Without In-hospital Revascularization.

Abstract

BACKGROUND: While use of P2Y12 receptor inhibitor is recommended by guidelines, few studies have examined its effectiveness among older non-ST-segment elevation myocardial infarction patients who did not undergo coronary revascularization. METHODS AND RESULTS: We included unrevascularized non-ST-segment elevation myocardial infarction patients ≥65 years discharged home from 463 ACTION Registry-GWTG hospitals from 2007 to 2010. Rates of discharge clopidogrel use were described for patients with no angiography, angiography without obstructive coronary artery disease (CAD; ≥50% stenosis in ≥1 vessel), and angiography with obstructive CAD. Two-year outcomes were ascertained from linked Medicare data and included composite major adverse cardiac events (defined as all-cause death, myocardial infarction readmission, or revascularization), and individual components. Outcomes associated with clopidogrel use were adjusted using inverse probability-weighted propensity modeling. Of 14 154 unrevascularized patients, 54.7% (n=7745) did not undergo angiography, 10.6% (n=1494) had angiography without CAD, and 34.7% (n=4915) had angiography with CAD. Discharge clopidogrel was prescribed for 42.2% of all unrevascularized patients: 37.8% without angiography, 34.1% without obstructive CAD at angiography, and 51.6% with obstructive CAD at angiography. Discharge clopidogrel use was not associated with major adverse cardiac events in any group: without angiography (adjusted hazard ratio [95% CI]: 0.99 [0.93-1.06]), angiography without CAD (1.04 [0.74-1.47]), and angiography with CAD (1.12 [1.00-1.25], Pinteraction=0.20). CONCLUSIONS: We found no association between discharge clopidogrel use and long-term risk of major adverse cardiac events among older, unrevascularized non-ST-segment elevation myocardial infarction patients. Clopidogrel use in this population requires further prospective evaluation.

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Citation

Published Version (Please cite this version)

10.1161/JAHA.115.002784

Publication Info

Hess, Connie N, Anne S Hellkamp, Matthew T Roe, Laine Thomas, Benjamin M Scirica, S Andrew Peng, Eric D Peterson, Tracy Y Wang, et al. (2016). Outcomes According to Cardiac Catheterization Referral and Clopidogrel Use Among Medicare Patients With Non-ST-Segment Elevation Myocardial Infarction Discharged Without In-hospital Revascularization. J Am Heart Assoc, 5(3). p. e002784. 10.1161/JAHA.115.002784 Retrieved from https://hdl.handle.net/10161/14992.

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Scholars@Duke

Roe

Matthew Todd Roe

Adjunct Professor in the Department of Medicine

My clinical activities focus upon general, preventive, and acute care cardiology.  I round regularly on the inpatient general cardiology and coronary care unit (CCU) services and i have a particular interest in the treatment and management of patients with acute myocardial infarction and cardiogenic shock.  In my outpatient clinic, I care for patients with a variety of cardiovascular conditions include chronic coronary artery disease, hypertension, hyperlipidemia, atrial fibrillation, congestive heart failure, aortic aneurysms, and peripheral arterial disease.  In this setting, I have a particular interest in cardiovascular risk factor modification and long-term treatment strategies to mitigate the risk of future cardiovascular events.

My research activities at the Duke Clinical Research Institute focus upon the coordination and leadership of randomized clinical trials evaluating new therapies for a variety of cardiovascular conditions (acute myocardial infarction, hyperlipidemia, coronary stent placement, peripheral arterial disease, and coronary artery disease) as well as observational registries that evaluate the same disease conditions.

Thomas

Laine Elliott Thomas

Professor of Biostatistics & Bioinformatics

As Deputy Director, Laine Thomas, PhD provides complementary leadership in strategy and development of the group and DCRI. She has an outstanding record of scientific and strategic collaboration, independent research, leadership and mentoring well known to her colleagues at the DCRI.

Thomas joined the DCRI in 2009. She serves as Associate Director for Biostatistics at DCRI and Associate Chair for Equity, Diversity and Inclusion within the Department of Biostatistics and Bioinformatics. She is a leader in developmental methods for observational and pragmatic studies. She has over 240 peer reviewed clinical and methodological publications arising from scientific collaboration in the therapeutic areas of cardiovascular disease, diabetes, uterine fibroids and SARS-CoV-2 virus. She led the statistical teams on the HERO COVID-19, ORBIT-AF I & II, ACTION-CMS, CHAMP-HF, and COMPARE-UF clinical registries and secondary analyses of the NAVIGATOR and ARISTOTLE clinical trials. She is the primary investigator of numerous methodological studies arising from these collaborations, addressing methods for causal inference in observational data, longitudinal treatment initiation, heterogeneous treatment effects and clinical trials augmented by external controls.


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