Abstract 32: Implementation of Bedside CYP2C19 Genotype Testing and Personalization of Antiplatelet Therapy in Cardiac Catheterization Lab

Abstract

Background: CYP2C19 polymorphisms affect clopidogrel metabolism and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). Although FDA recommended pharmacogenetic testing and alternative antiplatelet agents in CYP2C19 loss-of-function (LoF) allele carriers, implementation in practice has been minimal. Our goal is to personalize antiplatelet therapy using point-of-care (POC) assay to genotype patients immediately prior to PCI in a hospital cardiac catheterization lab. Methods: Appropriate P2Y 12 receptor antagonist therapy following non-emergent PCI based on bedside genetic testing (SpartanRx system) was initiated at Inova Heart and Vascular institute catheterization laboratory in February 2017. Patients were genotyped using buccal swab technique before proceeding to the catheterization laboratory. A best practice advisory (BPA) was implemented into the EPIC EMR prescription medication ordering system based on genotype. Poor (*2/*2, and *2/*3) and intermediate metabolizers (*1/*2, *1/*3, and *2/*17) were recommended more potent P2Y12 inhibitor therapy using BPA. Demographics, BPA compliance and 1 year outcomes including major adverse cardiac events (Cardiovascular death, MI, Ischemic stroke) and NACE (MACE + major bleeding) were collected. Results: Between 2/2017 to 12/2017, 1050 patients underwent POC genetic testing. The frequency of poor, intermediate, extensive, and ultra-rapid metabolizer status was 2.9%, 26.8%, 42.5%, and 27.9%, respectively. The highest percentage of poor metabolizers were observed in Middle-Eastern (12.1%) and Asian (8.9%) populations as compared to African Americans (n=3.4%) and Caucasians (1.1%). In patients treated with PCI (n=429), 28.9% were intermediate (n=112) or poor (n=12) clopidogrel metabolizers, with 87.1% of these patients receiving ticagrelor (n=84) or prasugrel (n=24) based on the BPA from genotype consortium. MACE (0.7%) and NACE (0.9%) rates were minimal as compared to historical controls (5-10%). Conclusions: CYP2C19 genotyping at the bedside facilitated early personalization of antiplatelet therapy according to BPA and is associated with low one year MACE and NACE rates.