Early clopidogrel versus prasugrel use among contemporary STEMI and NSTEMI patients in the US: insights from the National Cardiovascular Data Registry.


BACKGROUND: P2Y12 antagonist therapy improves outcomes in acute myocardial infarction (MI) patients. Novel agents in this class are now available in the US. We studied the introduction of prasugrel into contemporary MI practice to understand the appropriateness of its use and assess for changes in antiplatelet management practices. METHODS AND RESULTS: Using ACTION Registry-GWTG (Get-with-the-Guidelines), we evaluated patterns of P2Y12 antagonist use within 24 hours of admission in 100 228 ST elevation myocardial infarction (STEMI) and 158 492 Non-ST elevation myocardial infarction (NSTEMI) patients at 548 hospitals between October 2009 and September 2012. Rates of early P2Y12 antagonist use were approximately 90% among STEMI and 57% among NSTEMI patients. From 2009 to 2012, prasugrel use increased significantly from 3% to 18% (5% to 30% in STEMI; 2% to 10% in NSTEMI; P for trend <0.001 for all). During the same period, we observed a decrease in use of early but not discharge P2Y12 antagonist among NSTEMI patients. Although contraindicated, 3.0% of patients with prior stroke received prasugrel. Prasugrel was used in 1.9% of patients ≥75 years and 4.5% of patients with weight <60 kg. In both STEMI and NSTEMI, prasugrel was most frequently used in patients at the lowest predicted risk for bleeding and mortality. Despite lack of supporting evidence, prasugrel was initiated before cardiac catheterization in 18% of NSTEMI patients. CONCLUSIONS: With prasugrel as an antiplatelet treatment option, contemporary practice shows low uptake of prasugrel and delays in P2Y12 antagonist initiation among NSTEMI patients. We also note concerning evidence of inappropriate use of prasugrel, and inadequate targeting of this more potent therapy to maximize the benefit/risk ratio.





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Publication Info

Sherwood, Matthew W, Stephen D Wiviott, S Andrew Peng, Matthew T Roe, James Delemos, Eric D Peterson and Tracy Y Wang (2014). Early clopidogrel versus prasugrel use among contemporary STEMI and NSTEMI patients in the US: insights from the National Cardiovascular Data Registry. J Am Heart Assoc, 3(2). p. e000849. 10.1161/JAHA.114.000849 Retrieved from https://hdl.handle.net/10161/10320.

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Matthew William Sherwood

Adjunct Assistant Professor in the Department of Medicine

I am striving to become a clinical and research leader in structural heart disease and complex coronary disease, specifically in the use of antithrombotic agents after structural heart interventions.  I will also explore the significance of bleeding/vascular complications and stroke in these patients as well as potential therapies such as transfusion, and embolic protection devices.


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.

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