Antiplatelet Prescription Research Articles

Long-term adherence to low-dose aspirin therapy for cardiovascular prevention in routine clinical practice in United Kingdom and Germany

Abstract Background Low-dose aspirin is effective in the prevention of ischemic vascular events and studies have shown a preventative effect on colorectal cancer (CRC). However, adherence to therapy is likely an important factor for these benefits to be seen and non-adherence is associated with sub-optimal outcomes. Purpose To assess the long-term adherence to low-dose aspirin therapy in the primary and secondary cardiovascular (CVD) prevention population Methods This retrospective cohort study used data from United Kingdom (UK) – The Health Improvement Network Database and Germany (DE) – IQVIA Disease Analyzer and analyzed using an adaptation of Observational Health Data Sciences and Informatics (OHDSI) ATLAS Tool. Patients 18 years or older, with at least two prescriptions of low-dose aspirin (75–100mg) within the first year of index date during the study period between 2007 and 2018, and with at least 12 months of observation before and after the index date were included in the study. The patients with a CVD diagnosis or a CABG/PCI procedure before the index date or a prescription of dual antiplatelet at index date were classified as secondary CVD prevention. The remaining patients were classified as potential primary CVD prevention. The index date was first prescription of low-dose aspirin. Adherence was calculated using medication possession ratio (MPR) which is number of days of medication supplied within the refill interval divided by number of days in the refill interval. Long term adherence was divided in three categories namely patients with ≤2 years, 2-≤5 years, and 5-≤10 years of follow-up. Results The total number of patients receiving low-dose aspirin was 327,806 (183,089 in UK and 144,717 in DE with up to 10 years of follow-up). A total of 112,887 and 101,704 received low-dose aspirin for secondary CVD prevention; 70,202 and 43,013 potentially for primary CVD prevention in UK and DE, respectively. Median adherence to low-dose aspirin in UK and DE for patients with ≤2 years of follow-up was 88% and 80% for secondary CVD prevention, respectively; 84% and 74% for 2-≤5 years; and 75% and 59% for 5-≤10 years, respectively. Median adherence to low-dose aspirin in UK and DE for patients with ≤2 years was 76% and 75% for potential primary CVD prevention; 65% and 66% for 2-≤5 years; 49% and 49% for 5-≤10 years, respectively (Figure). Conclusion The long-term adherence to low dose aspirin was quite high with more than half the patients being adherent to their treatment. Overall, the adherence was higher in secondary compared to primary CVD prevention. The estimates for adherence might be underestimated due to potential over the counter use of low-dose aspirin. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Bayer AG

Impact of the CYP2C19*17 Allele on Outcomes in Patients Receiving Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention.

Genotyping for CYP2C19 no function alleles to guide antiplatelet therapy after percutaneous coronary intervention (PCI) improves clinical outcomes. Although results for the increased function CYP2C19*17 allele are also reported, its clinical relevance in this setting remains unclear. A collaboration across nine sites examined antiplatelet therapy prescribing and clinical outcomes in 3,342 patients after implementation of CYP2C19-guided antiplatelet therapy. Risk of major atherothrombotic and bleeding events over 12months after PCI were compared across cytochrome P450 2C19 isozyme (CYP2C19) metabolizer phenotype and antiplatelet therapy groups by proportional hazards regression. Clopidogrel was prescribed to a similar proportion of CYP2C19 normal (84.5%), rapid (82.9%), and ultrarapid metabolizers (80.6%) (P=0.360). Clopidogrel-treated normal metabolizers (20.4 events/100 patient-years; adjusted hazard ratio (HR) 1.00, 95% confidence interval (CI), 0.75-1.33, P=0.993) and clopidogrel-treated rapid or ultrarapid metabolizers (19.1 events/100 patient-years; adjusted HR 0.95, 95% CI, 0.69-1.30, P=0.734) exhibited no difference in major atherothrombotic events compared with patients treated with prasugrel or ticagrelor (17.6 events/100 patient-years). In contrast, clopidogrel-treated intermediate and poor metabolizers exhibited significantly higher atherothrombotic event risk compared with prasugrel/ticagrelor-treated patients (adjusted HR 1.56, 95% CI, 1.12-2.16, P=0.008). When comparing clopidogrel-treated rapid or ultrarapid metabolizers to normal metabolizers, no difference in atherothrombotic (adjusted HR 0.97, 95% CI, 0.73-1.29, P=0.808) or bleeding events (adjusted HR 1.34, 95% CI, 0.83-2.17, P=0.224) were observed. In a real-world setting of genotype-guided antiplatelet therapy, the CYP2C19*17 allele did not significantly impact post-PCI prescribing decisions or clinical outcomes. These results suggest the CYP2C19 *1/*17 and *17/*17 genotypes have limited clinical utility to guide antiplatelet therapy after PCI.

Antiplatelet patterns and outcomes in patients with atrial fibrillation not prescribed an anticoagulant after stroke

BackgroundTo determine association of discharge antiplatelet therapy prescription with 1-year outcomes among patients with AF admitted with acute ischemic stroke and discharged without oral anticoagulation. MethodsIn a retrospective cohort study from the Get With The Guidelines-Stroke registry, we identified all Medicare fee-for-service beneficiaries 65 years or older with AF or atrial flutter admitted with acute ischemic stroke and discharged without oral anticoagulation from April 2003 through December 2014, and we determined association of discharge antiplatelet therapy prescription with 1-year outcomes using Medicare claims data. Primary outcomes were 1-year mortality and composite endpoint of major adverse cardiovascular/neurologic/bleeding events (MACNBE). ResultsOf 64,228 subjects (median [interquartile range] age, 84 [78–89] years; 62.5% female), 54,621 (85.0%) were discharged with antiplatelet therapy, and 9607 (15.0%) were discharged with no antithrombotic therapy. The unadjusted rates of 1-year mortality were lower among patients receiving antiplatelet therapy (37.3%) than among those receiving no antithrombotic therapy (48.1%); unadjusted rates of MACNBE were lower for those receiving antiplatelet therapy (45.5%) compared with those receiving no antithrombotic therapy (55.2%). After adjusting for potential confounders, antiplatelet therapy prescription was associated with reduced 1-year mortality (adjusted hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.62–0.66, P < .001) and MACNBE (adjusted HR 0.69, 95% CI 0.67–0.71, P < .001). ConclusionsAmong Medicare beneficiaries with AF admitted for acute ischemic stroke but not discharged on oral anticoagulant therapy, antiplatelet therapy, compared with no antithrombotic therapy, was associated with reduced 1-year mortality and MACNBE.

Prescription of oral anticoagulants and antiplatelets for stroke prophylaxis in atrial fibrillation: nationwide time series ecological analysis.

To investigate trends in the prescription of oral anticoagulants (OACs) and antiplatelet agents for atrial fibrillation (AF). Prescription data for 450518 patients with AF from 3352 General Practices in England, was obtained from the GRASP-AF registry, 2009-2018. Annualized temporal trends for OAC and antiplatelet prescription were reported according to eligibility based on stroke risk (CHADS2 or CHA2DS2-VASc scores ≥1 or >2, respectively). From 2009 to 2018, the prevalence of AF increased from 1.6% [95% confidence interval (CI) 1.5-1.7%] to 2.4% (2.3-2.5%), and for those with AF the proportion prescribed OAC increased from 47.6% to 75.0% (P-trend < 0.001; relative risk 1.57, 95% CI 1.55-1.60) and for antiplatelet decreased from 37.4% to 9.2% (P-trend < 0.001). In early-years (2009-2013), eligible patients aged ≥80 years were less likely to be prescribed OAC than patients aged <80 years [odds ratio (OR) 0.55, 95% CI 0.51-0.59 for CHADS2≥1 in 2009] (all P-trends < 0.001). This 'OAC prescription gap' reduced over the study period (OR 0.93, 0.90-0.96 in 2018). Whilst the prescription of direct oral anticoagulant (DOAC) as a proportion of all OAC increased from 0.1% (95% CI 0.0-0.2%) in 2011 to 58.8% (58.4-59.2%) in 2018, it was inversely associated with patient age (P-trend < 0.001) and their risk of stroke. Between 2009 and 2018, in England, the use of OAC for stroke prophylaxis in AF increased, with DOAC accounting for over half of OAC uptake in 2018. Despite a reduction in the OAC-prescription gap, a new paradox exists relating to DOAC prescription for the elderly and those at higher risk of stroke.

Contemporary trends in antiplatelet prescription in Australia

Contemporary trends in antiplatelet prescription in Australia

Discharge Prescription Patterns for Antiplatelet Therapy Following Lower Extremity Peripheral Vascular Intervention.

Despite current guidelines suggesting a benefit for dual antiplatelet therapy (DAPT) following peripheral vascular intervention (PVI), there are limited data on antiplatelet prescribing patterns post-procedure. We attempted to determine variables associated with DAPT prescription following lower extremity PVI. Retrospective analysis of patients undergoing lower extremity PVI in the Vascular Quality Initiative (2017-2018) was performed. Participants not on anticoagulation or DAPT before the procedure were considered for the final analysis. Postdischarge antiplatelet therapy regimen rates were determined (none, aspirin only, P2Y12 inhibitor only, and DAPT). Multivariate logistic regression was performed to determine variables associated with DAPT initiation compared with those discharged on single-agent or no antiplatelet therapy. A total of 16 597 procedures were included for analysis, with 49% initiated on DAPT post-PVI. Male sex (odds ratio [OR], 1.12 [95% CI, 1.05-1.20]), smoking (OR, 1.20 [95% CI, 1.09-1.32]), and coronary artery disease (OR, 1.19 [95% CI, 1.11-1.27]) were associated with an increased likelihood of post-PVI DAPT prescription. Procedures requiring multiple types of interventions (OR, 1.28 [95% CI, 1.15-1.42]), stent placement (OR, 1.16 [95% CI, 1.06-1.27]), and with complications (OR, 1.31 [95% CI, 1.14-1.52]) were also positively associated with DAPT prescription. In patients not already receiving anticoagulation or on DAPT at the time of lower extremity PVI, prescription of DAPT following intervention is ≈50%. Multiple factors were associated with the decision for DAPT versus single antiplatelet therapy, and further study is required to understand how this affects postintervention adverse limb and cardiovascular events.

Inappropriate use of antiplatelet agents for primary prevention in nursing homes: An Italian multicenter observational study.

The benefits of antiplatelets to prevent cardio- and cerebrovascular disease are recognized and appropriate only for "secondary prevention." This multicenter retrospective study was designed to (i) examine the prevalence of residents receiving antiplatelets for primary and secondary cardio- and cerebrovascular prevention, and (ii) evaluate the predictors of inappropriate antiplatelet prescription. This study was conducted in a sample of Italian long-term care nursing homes (NHs). Appropriate use of antiplatelets was defined in accordance with the strongest evidence-based indications. Among the 2579 patients recruited from 27 long-term care NHs (age mean ± SD: 86.8 ± 7.3; women: 1995; 77.4%), 1092 were treated with antiplatelets (42.3%) and 619 (56.7%) were receiving antiplatelet agents for inappropriate primary prevention of cardio- or cerebrovascular atherothrombotic events. Age, dementia or cerebral atherosclerosis, congestive heart failure, peripheral vascular disease, diabetes without chronic complication and hypertension were predictors of inappropriate prescription of antiplatelets. Patients inappropriately treated with antiplatelets also had a higher risk of receiving proton pump inhibitors than those appropriately not treated in univariate (OR 95% CI = 2.79 (2.25-3.46, p < 0.0001) and multivariate models (OR 95% CI 2.71 (2.16-3.40, p < 0.0001). Most patients receiving antiplatelet agents in NHs are being inappropriately treated for primary prevention of cardio- or cerebrovascular disease. NH residents with diagnosis of dementia or cerebral atherosclerosis, congestive heart failure, peripheral vascular disease, diabetes without chronic complication and hypertension seemed more likely to receive antiplatelets inappropriately. Patients without an evidence-based indication for antiplatelets also received proton-pump inhibitors in an unnecessary "prescribing cascade," which should be assessed for de-prescribing. Geriatr Gerontol Int 2020; 20: 828-832.

Clinical Utility of CYP2C19 Genotype-Guided Antiplatelet Therapy in Patients at Risk of Adverse Cardiovascular and Cerebrovascular Events: A Review of Emerging Evidence.

In patients undergoing percutaneous coronary intervention (PCI), the standard of care is dual antiplatelet therapy with a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin. Current clinical practice guidelines now recommend more potent P2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel in acute coronary syndrome (ACS). However, clopidogrel remains the most commonly prescribed P2Y12 inhibitor in the setting of PCI and is also the preferred agent in the treatment and secondary prevention of stroke. Clopidogrel is a prodrug that requires bioactivation by the CYP2C19 enzyme. It has been shown that clopidogrel use in patients who are CYP2C19 no function allele carriers are associated with impaired antiplatelet inhibition and a higher risk of major adverse cardiovascular and cerebrovascular events. Compared to clopidogrel, prasugrel and ticagrelor clinical response is not impacted by CYP2C19 genotype. Even with a demonstrated increased risk of adverse outcomes in CYP2C19 no function allele carriers treated with clopidogrel, routine implementation of CYP2C19 genotyping to guide antiplatelet therapy selection has remained controversial and has not been widely adopted. Recent results from multiple prospective randomized and nonrandomized clinical trials investigating the use of CYP2C19 genotype-guided antiplatelet therapy following PCI have advanced the evidence base demonstrating the clinical utility of this strategy. Multiple recent studies have examined the effects of CYP2C19 genotype on clopidogrel outcomes in the setting of stroke and neurointerventional procedures. In this review, we discern the clinical utility of using CYP2C19 genotype testing to guide antiplatelet therapy prescribing by evaluating the impact of CYP2C19 genotype-guided selection of antiplatelet therapy on clinical outcomes, summarizing emerging data from cardiovascular and neurology clinical studies, and discussing implications for clinical practice guidelines, remaining knowledge gaps and future research directions.

Stroke prevention in atrial fibrillation changes after dabigatran availability in China: The GLORIA-AF registry.

BackgroundUntil the approval of dabigatran etexilate, treatment choices for stroke prevention in patients with atrial fibrillation (AF) were vitamin K antagonists (VKAs) or antiplatelet drugs. This analysis explored whether availability of non‐vitamin K antagonist oral anticoagulants post‐dabigatran approval was associated with changing treatment patterns in China.MethodsGlobal Registry on Long‐Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA‐AF) collected data on antithrombotic therapy choices for patients with newly diagnosed nonvalvular AF at risk for stroke. In China, enrollment in phase 1 (before dabigatran approval) and phase 2 (after dabigatran approval) occurred from 2011 to 2013 and 2013 to 2014, respectively. Analyses were restricted to sites within China that contributed patients to both phases. The weighted average of the site‐specific results was estimated for standardization. Sensitivity analyses used multiple regression.ResultsThirteen sites participated in both phase 1 (419 patients) and phase 2 (276 patients), 76.1% and 16.0% were known to be at high risk for stroke (CHA2DS2‐VASc ≥2) and bleeding (HAS‐BLED ≥3); 55.5% were male. In phase 1, 16.7%, 61.6%, and 21.7% of patients were prescribed oral anticoagulants (OACs), antiplatelet agents, and no treatment, respectively. Respective proportions were 26.4%, 40.6%, and 33.0% in phase 2. The absolute increase in the site‐standardized proportion of patients prescribed OACs after dabigatran availability was 9.9% (95% confidence interval [CI]: 3.7%‐16.0%). There was a standardized 17.3% (95% CI: −24.3% to −10.4%) absolute decrease in antiplatelet agent use.ConclusionsThere was an increase in OAC and decrease in antiplatelet agent prescription since dabigatran availability in China. However, a large proportion of AF patients at risk for stroke remained untreated.

One‐year efficacy and safety of prasugrel and ticagrelor in patients with acute coronary syndromes: Results from a prospective and multicentre ACHILLES registry

Prasugrel and ticagrelor have demonstrated higher efficacy than clopidogrel in their main clinical trials for patients with acute coronary syndrome (ACS). However, the long-term prognosis and different clinical characteristics related to the type of antiplatelet prescription in current clinical practice ACS patients have not been analysed in depth. The objective of this study was to analyse the clinical profile of ACS and the efficacy and safety of novel oral P2Y12 inhibitors in current clinical practice patients discharged afterACS. We collected data from the ACHILLES registry, and an observational, prospective and multicentre registry of patients discharged after ACS. We analysed baseline characteristics, clinical profile and therapy during ACS admission and compared with the different treatments at discharge. After 1year of follow-up, ischaemic and major bleeding events were analysed. Multivariate Cox regression analysis and Kaplan Meier curves were also plotted. Of 1717 consecutive patients, 1294 (75.4%) were discharged with a P2Y12 inhibitor without oral anticoagulation. Novel oral P2Y12 inhibitors were indicated in 47%. Patients treated with clopidogrel were elderly (69.1±13.4 vs 60.4±11.5years; P<.001) and had a higher prevalence of cardiovascular risk factors. GRACE and CRUSADE scores were higher in the clopidogrel than in novel oral P2Y12 inhibitors group (P<.001). After 1year of follow-up, 64(5.0%/year) patients had a new myocardial infarction, 127(10.0%/year) had a major adverse cardiovascular event (MACE) and 78(6.1%/year) died. Patients treated with clopidogrel had a significantly higher annual rate of cardiovascular mortality, MACE and all-cause mortality (allP<.001) without differences in major bleeding (P=.587) compared with novel oral P2Y12 inhibitors. After multivariate adjustment for the main clinical variables related to adverse prognosis in ACS patients, the discharge with novel oral P2Y12 inhibitors therapy was independently associated with lower risk of all-cause mortality (HR0.49, 95% CI [0.24-0.98], P=.044) and lower risk of MACE (HR0.64, 95% CI [0.41-0.98], P=.044). In this prospective, observational and current clinical practice ACS registry, the use of novel oral P2Y12 inhibitors was associated with a reduction in adverse events compared with clopidogrel in patients with ACS. Novel oral P2Y12 inhibitors prescription at discharge was independently associated with lower all-cause mortality and MACE without differences in bleeding events. However, clopidogrel remained the most common P2Y12 inhibitor employed for ACS, especially in older and high-risk patients.

Abstract 159: Trends in Dual Antiplatelet Therapy Prescription Patterns for Secondary Prevention in Patients With Noncardioembolic Ischemic Stroke

Background: The recommendations for dual antiplatelet (DAPT aspirin + clopidogrel) for secondary stroke prevention has evolved over time. Following the publication of CHANCE trial (07/2013), the AHA/ASA updated the DAPT recommendations from Class III harm (10/2010) for patient with noncardioembolic ischemic stroke, to Class IIb benefit ≥ risk (02/2014), and Class IIa benefit &gt;&gt; risk (03/2018) for a subgroup of patients with minor stroke (NIHSS≤3). Subsequent to the last guideline update, the POINT trial (05/2018) provided further support for the effectiveness of DAPT. Methods: We evaluated antiplatelet prescription patterns of 1,024,074 noncardioembolic ischemic stroke survivors (median age 65 years and 46% women) eligible for antiplatelet therapy (no contraindications) and discharged from the Get With The Guidelines-Stroke Hospitals between Q1 2011 and Q1 2019. Results: Baseline patient characteristics were similar within the four periods: pre-CHANCE (01/2011-07/2013), pre-2014 guideline update (08/2013-02/2014), pre-POINT/2018 guideline update (03/2014-05/2018), and post-POINT (06/2018-03/2019). Use of DAPT gradually increased from 16.7% in the pre-CHANCE period, to 19.4% pre-2014 guideline update, 23.3% pre-POINT/2018 guideline update, and 29.8% post-POINT period (p&lt;0.001, Figure). Yet increase in DAPT use was observed over time for individuals with NIHSS≤3 (17.1%, 19.9%, 24.1%, and 31.4%, p&lt;0.001) and those with NIHSS&gt;3 (18.7%, 22.8%, 28.3%, and 28.3%, p&lt;0.001). Conclusions: A sustained increase in DAPT use for secondary stroke prevention was observed after publication of pivotal trials and AHA guideline updates. While recommended for minor strokes or TIA only, such increase was also observed in ischemic stroke patients with NIHSS&gt;3, where the risk-benefit ratio of DAPT remains to be established.

Prospective CYP2C19 Genotyping to Guide Antiplatelet Therapy Following Percutaneous Coronary Intervention: A Pragmatic Randomized Clinical Trial.

CYP2C19 loss-of-function alleles impair clopidogrel effectiveness after percutaneous coronary intervention, but the clinical impact of implementing CYP2C19 genotyping in a real-world setting is unknown. The purpose of the study was to determine whether returning CYP2C19 genotype results along with genotype-guided pharmacotherapy recommendations using a rapid turnaround test would change antiplatelet prescribing following percutaneous coronary intervention.The primary outcome was the rate of prasugrel or ticagrelor prescribing in each arm. Secondary outcomes included agreement to the genotype-guided recommendations. At the time of percutaneous coronary intervention, participants were randomly assigned to prospective rapid point-of-care genotyping of CYP2C19 major alleles (*2, *3, *17) via salivary swab (genotyped group) or no genotyping (usual care) to guide antiplatelet drug selection. Interventional cardiologists at 2 cardiac catheterization laboratories within the same health system were provided genotype information along with genotype-guided pharmacotherapy recommendations. A total of 504 participants were randomized, 249 to the genotyped and 255 to the usual care group. The participants were primarily men (73%); age, 63±10 years; and 50% had acute coronary syndromes. In the genotyped group, 28% were carriers of loss-of-function alleles (*2, *3). The use of prasugrel or ticagrelor was significantly higher in the genotyped group compared with the usual care group (30% versus 21%; odds ratio, 1.60 [95% CI, 1.07-2.42]; P=0.03). Within the genotyped group, 53% of loss-of-function allele carriers were started on prasugrel/ticagrelor, while 47% were started on clopidogrel. In a randomized controlled trial of clinical CYP2C19 genotyping implementation, pharmacogenetic test results significantly influenced antiplatelet drug prescribing; however, almost half of CYP2C19 loss-of-function carriers continued to receive clopidogrel. Interventional cardiologists consider both clinical and genetic factors when selecting antiplatelet therapy following percutaneous coronary intervention. URL: http://www.clinicaltrials.gov. Unique Identifier: NCT02508116.

568 Trends in Second Antiplatelet Prescriptions in Australia Over the Last Ten Years

568 Trends in Second Antiplatelet Prescriptions in Australia Over the Last Ten Years

Umbrella review and meta-analysis of antiplatelet therapy for peripheral artery disease.

The literature on antiplatelet therapy for peripheral artery disease has historically been summarized inconsistently, leading to conflict between international guidelines. An umbrella review and meta-analysis was performed to summarize the literature, allow assessment of competing safety risks and clinical benefits, and identify weak areas for future research. MEDLINE, Embase, DARE, PROSPERO and Cochrane databases were searched from inception until January 2019. All meta-analyses of antiplatelet therapy in peripheral artery disease were included. Quality was assessed using AMSTAR scores, and GRADE analysis was used to quantify the strength of evidence. Data were pooled using random-effects models. Twenty-eight meta-analyses were included. Thirty-three clinical outcomes and 41 antiplatelet comparisons in 72 181 patients were analysed. High-quality evidence showed that antiplatelet monotherapy reduced non-fatal strokes (3 (95 per cent c.i. 0 to 6) fewer per 1000 patients), In symptomatic patients, it reduced cardiovascular deaths (8 (0 to 16) fewer per 1000 patients), but increased the risk of major bleeding (7 (3 to 14) more events per 1000). In asymptomatic patients, monotherapy reduced non-fatal strokes (5 (0 to 8) fewer per 1000), but had no other clinical benefit. Dual antiplatelet therapy caused more major bleeding after intervention than monotherapy (37 (8 to 102) more events per 1000), with very low-quality evidence of improved endovascular patency (risk ratio 4·00, 95 per cent c.i. 0·91 to 17·68). Antiplatelet monotherapy has minimal clinical benefit for asymptomatic peripheral artery disease, and limited benefit for symptomatic disease, with a clear risk of major bleeding. There is a lack of evidence to guide antiplatelet prescribing after peripheral endovascular intervention.

Four-year trends in oral anticoagulant use and declining rates of ischemic stroke among 194,030 atrial fibrillation patients drawn from a sample of 12 million people

Administrative data were used to investigate changes in hospitalizations for atrial fibrillation (AF), AF-related stroke, and treatment patterns between 2012 and 2016. From the 'Ricerca e Salute' database, a population- and patient-based repository involving >12 million inhabitants and linking demographics, prescriptions, and hospital discharge records, all patients discharged alive with a diagnosis of AF between 2012 and 2015 were followed for 1 year. A total of 194,030 AF patients were included. The number of AF cases increased ~10% over time, from 4.0 per 1,000 inhabitants in 2012 to 4.4 per 1,000 in 2015. At 1 year, hospitalizations for ischemic stroke decreased from 21.3 per 1,000 patients with AF in 2012-2013 to 14.7 per 1,000 in 2015-2016 (-31%, 95% CI -18 to -41). Over the same period, oral anticoagulant (OAC) use increased from 56.7% to 64.4% (+14%, 95% CI +8 to +26), vitamin K antagonist use decreased (from 55.9 to 36.7%; -34%, 95% CI -21 to -44), whereas direct OACs (DOACs) increased (from <1% in 2012 to 27.7% in 2015). Antiplatelet prescriptions fell from 42.6% in 2012 to 28.1% in 2015. Hospitalizations for major bleeds, mainly gastrointestinal, increased from 1.5‰ in 2012-2013 to 2.3‰ in 2015-2016, whereas hemorrhagic stroke admissions decreased from 6.5‰ to 4.1‰. There was a slight increase in the prevalence of AF between 2012 and 2015, whereas the overall use of antiplatelet agents decreased and that of OAC, particularly DOACs, increased. Over the same period, 1-year hospitalizations for ischemic stroke declined substantially, with a declining rate of hemorrhagic strokes.

The appropriateness of antiplatelet and anticoagulant drug prescriptions in hospitalized patients in an internal medicine ward.

Polypharmacy increases the risk of potentially inappropriate prescribing. STOPP&START criteria identify a group of drugs representing inappropriate medication and a group of drugs representing potential prescribing omissions. To evaluate the appropriateness of prescription of antiplatelet and anticoagulant drugs in a sample of patients admitted to an internal medicine ward and their impact on three different outcomes: length of hospitalization, intra-hospital death, and risk of re-admission in the hospital. We analyzed a cohort of 485 inpatients followed for 1year after discharge from the hospital. The study sample had a mean age of 70.4 ± 17.6years, and 48.9% were female. Clinical indication for antiplatelet was not appropriate in 41.2% of the subjects. Anticoagulant therapy was not appropriate in 22.8% of the subjects: there was incorrect clinical indication in 5/33 and inappropriate dosing in 28/33. START criteria for antiplatelet drug, but neither STOPP criteria for antiplatelet nor for anticoagulant was positively associated with the length of hospitalization (t = 3.08, p < 0.01). START criteria for anticoagulant medication were associated with greater odds of intra-hospital mortality (OR 5.16, 95% CI 1.92-13.85, p < 0.0001) and with lower odds of re-admission to the hospital within 12months (OR 0.38, 95% CI 0.18-0.80, p < 0.01). The non-prescription of antiplatelet is associated with longer length of hospitalization. The presence of START criteria for anticoagulant is associated with increased risk of intra-hospital death. The appropriateness of prescription is a global burden especially in older subjects, while it increases the risk of fatal and non-fatal complications, side effects, and, consequently, higher health-care costs.

P3842One-year efficacy and safety of prasugrel and ticagrelor in patients with Acute Coronary Syndromes: results from a prospective and multicenter ACHILLES Registry

Abstract Background Prasugrel and Ticagrelor have demonstrated higher efficacy than clopidogrel in their main clinical trials for patients with Acute Coronary Syndrome (ACS). However, the long-term prognosis and different clinical characteristics related with the type of antiplatelet prescription in current clinical practice ACS patients have not been analyzed in depth. Purpose The objective of this study was to analyze the clinical profile of ACS and the efficacy and safety of new antiplatelet drugs (NAD) in current clinical practice patients discharged after an ACS. Methods We collected data from ACHILLES registry, and observational, prospective and multicenter registry of patients discharged after an ACS. We analyzed baseline characteristics, clinical profile and therapy during ACS admission and compared with the different treatments at discharge. After 1 year of follow-up, ischaemic and major bleeding events were analyzed. Multivariate Cox regression analysis and Kaplan Meier curves were also plotted. Results Of 1,717 consecutive patients, 1,294 (75.4%) were discharged with a P2Y12 inhibitor without oral anticoagulation. NAD was indicated in 47%. Patients treated with clopidogrel were elderly (69.1±13.4 vs. 60.4±11.5 years; p&lt;0.001) and with a higher prevalence of cardiovascular risk factors. GRACE and CRUSADE score were higher in the clopidogrel than in NAD group (p&lt;0.001). After 1 year of follow-up, 64 (5.0%/year) patients had a new myocardial infarction, 127 (10.0%/year) had a MACE and 78 (6.1%/year) patients died. Patients treated with clopidogrel had significantly higher annual rate of cardiovascular mortality, MACE and all cause-mortality (all of them p&lt;0.001) without differences in major bleeding (p=0.587) compared with NAD therapy. After multivariate adjustment for the main clinical variables related with adverse prognosis in ACS patients, the discharge with NAD was independently associated with lower risk of all-cause mortality [HR 0.49, 95% CI (0.24–0.99); p=0.043] and lower risk of MACE [HR 0.65, 95% CI (0.43–0.99); p=0.049]. Event Free Survival according NAD Use Conclusions In this prospective, observational and current clinical practice ACS registry, the use of NAD was associated with a reduction of adverse events compared with clopidogrel in patients with ACS. NAD prescription at discharge was independently associated with lower all-cause mortality and MACE without differences in bleeding events. However, clopidogrel remained the most common P2Y12 inhibitor employed for ACS, especially in older and high risk population.

Cerebral amyloid angiopathy-related transient focal neurological episodes: A transient ischemic attack mimic with an increased risk of intracranial hemorrhage

BackgroundTransient focal neurological episodes (TFNEs) are a recently recognized clinical presentation of cerebral amyloid angiopathy (CAA). Our aim was to describe the clinical and radiological features of a series of patients with AS. MethodsWe included 11 patients presenting with recurrent transient focal neurological symptoms and radiological features related to CAA. ResultsMean age was 76,6 and 5 patients were women. All patients reported transient, stereotyped, and recurrent episodes (6 patients had >10 episodes). Gradual spread of the symptoms was recorded in 9 patients. Initially, 3 patients were misdiagnosed as having recurrent transient ischemic attack (TIA), 6 as having seizures, and 2 as having both. Two patients were prescribed antiplatelet therapy. A cerebral MRI with T2* gradient-recalled echo sequence revealed cortical superficial siderosis (cSS) in 5 patients, cortical microbleeds in 1 patient, and both features in 5 cases. After a median follow-up of 36 months, intracranial hemorrhage (ICH) was recorded in 4 patients. All 4 had cSS in the previous cerebral MRI, and 1 was on antiplatelet therapy. ConclusionCAA-related TFNEs are an underdiagnosed entity, often mimicking TIA, seizures, or migraine aura. This misdiagnosis can lead to the prescription of antiplatelet or anticoagulant therapy, which increases the risk of ICH. Our results suggest that cSS might be a radiological marker that is closely related to an increased risk of bleeding. A T2* gradient-recalled echo MRI should be performed in elderly patients with transient focal neurological symptoms suggestive of CAA.

A retrospective cohort study of oral anticoagulant treatment in patients with acute coronary syndrome and atrial fibrillation

ObjectiveTo examine the real-world patterns of oral anticoagulant (OAC) therapy in patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) in Southern China undergoing percutaneous coronary intervention (PCI) and...

Appropriateness of prescription of oral anticoagulant therapy in acutely hospitalized older people with atrial fibrillation. Secondary analysis of the SIM-AF cluster randomized clinical trial.

To assess the appropriateness of oral anticoagulant (OAC) prescription and its associated factors in acutely hospitalized elderly patients. Data were obtained from the prospective phase of SIM-AF (SIMulation-based technologies to improve the appropriate use of oral anticoagulants in hospitalized elderly patients with Atrial Fibrillation) randomized controlled trial, aimed to test whether an educational intervention improved OAC prescription, compared to current clinical practice, in internal medicine wards. In this secondary analysis, appropriateness of OAC prescription was assessed at hospital admission and discharge. For 246 patients, no significant differences were found between arms (odds ratio 1.38, 95% confidence interval [CI] 0.84-2.28) in terms of appropriateness of OAC prescription. Globally, 92 patients (37.4%, 95% CI=31.6-43.6%) were inappropriately prescribed or not prescribed at hospital discharge. Among 51 patients inappropriately prescribed, 82% showed errors on dosage, being mainly under-dosed (n=29, 56.9%), and among 41 inappropriately not prescribed, 98% were taking an antiplatelet drug. Factors independently associated with a lower probability of appropriateness at discharge were those related to a higher risk of bleeding (older age, higher levels of aspartate aminotransferase, history of falls, alcohol consumption) and antiplatelet prescription at admission. The prescription of OACs at admission was the strongest predictor of appropriateness at discharge (odds ratio=7.43, 95% CI=4.04-13.73). A high proportion of hospitalized older patients with AF remains inappropriately prescribed or nonprescribed with OACs. The management of these patients at hospital admission is the strongest predictor of prescription appropriateness at discharge.