The Effect of De-escalated Switching Dual Antiplatelet Therapy after Acute Myocardial Infarction in Patients undergoing Percutaneous Coronary Intervention: Real-world Data from a Nationwide Cohort Study - European Medical Journal
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The Effect of De-escalated Switching Dual Antiplatelet Therapy after Acute Myocardial Infarction in Patients undergoing Percutaneous Coronary Intervention: Real-world Data from a Nationwide Cohort Study

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Authors:
Chien-Yi Hsu,1,2,3 *Jong-Shiuan Yeh,2,3,4 Chun-Yao Huang,1,2,3 Li-Nien Chien5
Disclosure:

The authors have declared no conflict of interests.

Acknowledgements:

This study was supported by the Health and Clinical Research Data Center at School of Public Health, Taipei Medical University, Taipei, Taiwan.

Citation
EMJ Cardiol.. ;7[1]:72-73.

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.

BACKGROUND

The dual antiplatelet therapy (DAPT) de-escalation strategy is considered and used by many clinical physicians when treating acute coronary syndrome patients to reduce further risk of bleeding.1,2 DAPT de-escalation strategies have been investigated in several clinical studies, but the data remain limited and conflicting;3-5 therefore, current clinical practice guidelines provide no clear recommendations on de-escalation of P2Y12 inhibitors.6,7 The aim of the current study was to examine the effect of de-escalation of P2Y12 inhibitor in DAPT on cardiovascular events and bleeding complications after acute myocardial infarction (AMI) in patients undergoing percutaneous coronary intervention (PCI).

METHODS

Using a nationwide database in Taiwan between July 1st 2013 and December 31st 2015, (ticagrelor was first approved by the National Health Insurance (NHI) Administration of Taiwan after July 1st 2013), the authors retrospectively evaluated patients who had received PCI during AMI hospitalisation and were initially on aspirin and ticagrelor and without adverse events at 3 months. The main outcome measurements included: 1) cardiovascular events: death and AMI readmission; 2) major bleeding events: gastrointestinal bleeding or other noncritical site bleeding that required transfusion of >2 U packed red blood cells, or intracerebral haemorrhage and other critical site bleeding leading to hospitalisation; 3) nonmajor clinically relevant bleeding: inpatient or outpatient visit for gastrointestinal and other noncritical site bleeding.

RESULTS

In total, 1,903 patients were identified as switched DAPT (to aspirin and clopidogrel) cohort and 4,059 patients as unswitched DAPT (continued on aspirin and ticagrelor) cohort. With a mean follow-up of 14 months, the incidence rates (per 100 person-year) of death and AMI readmission were 3.97 and 3.84 in the switched cohort and 1.83 and 2.23 in the unswitched cohort, respectively. An inverse probability of treatment weighted approach was used to balance baseline differences between the two groups. After adjustment for clinical variables, the switched cohort had a higher risk of death (adjusted hazard ratio [aHR] 2.18; 95% confidence interval [CI]: 1.62–2.93; p<0.001) and AMI readmission (aHR] 1.72; 95% CI: 1.27–2.34) compared with the unswitched cohort. When compared to the risk of bleeding complications, there was no significant difference between the two groups. In patients aged ≥65 years, the risk of death and AMI readmission in the switched group were still higher than that in the unswitched group (aHR 3.30; 95% CI: 2.19–4.98, aHR 2.40; 95% CI: 1.50–3.82, respectively).

Figure 1: Survival analysis for death between unswitched and switched groups.

CONCLUSION

There is a possibility that unguided de-escalation of P2Y12 inhibitor in DAPT is associated with a higher risk of death and AMI readmission in Taiwanese patients with AMI undergoing PCI. The caution surrounding unguided DAPT de-escalation is justified by the findings of this study and is reflected in real-world practice.

References
Rollini F et al. Switching P2Y12-receptor inhibitors in patients with coronary artery disease. Nat Rev Cardiol. 2016;13(1):11-27. Angiolillo DJ et al. International expert consensus on switching platelet P2Y12 receptor-inhibiting therapies. Circulation. 2017;136(20):1955-75. Cuisset T et al. Benefit of switching dual antiplatelet therapy after acute coronary syndrome: The TOPIC (timing of platelet inhibition after acute coronary syndrome) randomized study. Eur Heart J. 2017;38(41):3070-8. Sibbing D et al. Guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention (TROPICAL-ACS): A randomised, open-label, multicentre trial. Lancet. 2017;390(10104):1747-57. De Luca L et al. Incidence and outcome of switching of oral platelet P2Y12 receptor inhibitors in patients with acute coronary syndromes undergoing percutaneous coronary intervention: The SCOPE registry. EuroIntervention. 2017;13(4):459-66. Amsterdam EA et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139-228. Levine GN et al. Expert consensus document: World Heart Federation expert consensus statement on antiplatelet therapy in East Asian patients with ACS or undergoing PCI. Nat Rev Cardiol. 2014;11(10):597-606.