Oral Antiplatelet Use Research Articles

Preadmission Antiplatelet Use and Associated Outcomes and Costs Among ICU Patients With Intracranial Hemorrhage.

Patients with intracranial hemorrhage (including intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic hemorrhage) are commonly admitted to the intensive care unit (ICU). Although indications for oral antiplatelet agents are increasing, the impact of preadmission use on outcomes in patients with intracranial hemorrhage admitted to the ICU is unknown. We sought to evaluate the association between preadmission oral antiplatelet use, in-hospital mortality, resource utilization, and costs among ICU patients with intracranial hemorrhage. We retrospectively analyzed a prospectively collected registry (2011-2016) and included consecutive adult patients from 2 hospitals admitted to ICU with intracranial hemorrhage. Patients were categorized on the basis of preadmission oral antiplatelet use. We excluded patients with preadmission anticoagulant use. The primary outcome was in-hospital mortality and was analyzed using a multivariable logistic regression model. Contributors to total hospital cost were analyzed using a generalized linear model with log link and gamma distribution. Of 720 included patients with intracranial hemorrhage, 107 (14.9%) had been using an oral antiplatelet agent at the time of ICU admission. Oral antiplatelet use was not associated with in-hospital mortality (adjusted odds ratio: 1.31 [95% confidence interval [CI]: 0.93-2.22]). Evaluation of total costs also revealed no association with oral antiplatelet use (adjusted ratio of means [aROM]: 0.92 [95% CI: 0.82-1.02, P = .10]). Total cost among patients with intracranial hemorrhage was driven by illness severity (aROM: 1.96 [95% CI: 1.94-1.98], P < .001), increasing ICU length of stay (aROM: 1.05 [95% CI: 1.05-1.06], P < .001), and use of invasive mechanical ventilation (aROM: 1.76 [95% CI: 1.68-1.86], P < .001). Among ICU patients admitted with intracranial hemorrhage, preadmission oral antiplatelet use was not associated with increased in-hospital mortality or hospital costs. These findings have important prognostic implications for clinicians who care for patients with intracranial hemorrhage.

Neuro-Interventional Use of Oral Antiplatelets: A Survey of Neuro-Endovascular Centers in the United States and Review of the Literature

Background: Intra- and postprocedural thrombosis are major complication of aneurysmal coil embolization, stent-assisted coiling, and pipeline embolization. The common but unproven practice of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in neuro-endovascular patients is inferred from the cardiology literature without large clinical trials to support it in neuro-endovascular patients. Objective: We conducted an electronic survey to identify practice variations surrounding the use of oral antiplatelets in patients undergoing endovascular neuro-interventional procedures across neuro-endovascular centers in the United States. Methods: An electronic survey was distributed via the Web. Any practicing neuro-intensive care unit (ICU), neuro-interventional or stroke physician, pharmacist, physician assistant, or nurse practitioner was eligible to respond to this survey between June and October 2017. Results: A total of 33 responses were collected during the survey period. A response rate of 16% was calculated after taking into account all comprehensive stroke centers in the United States. Aspirin and clopidogrel was the standard-of-care antiplatelet regimen utilized in the majority of institutions (82%). Alternatively, 4 institutions used monotherapy (aspirin [n = 2], clopidogrel [n = 1], either aspirin or clopidogrel [n = 1]) and 2 institutions reported practitioner-dependent practices. Just under half of the centers reported ticagrelor as the primary alternative in clopidogrel nonresponders (48%). Conclusion: Dual antiplatelet therapy with aspirin and clopidogrel appears to be standard of care in this setting based on our survey. About half of responding institutions use ticagrelor in cases where clopidogrel resistance is suspected. Large society-wide patient registries are needed to provide data for future safety and efficacy studies.

Oral antiplatelets in primary and secondary prevention of myocardial infarction: a review.

There are a number of guidelines and articles available for the use of oral antiplatelets for primary and secondary prevention of myocardial infarction (MI). Antiplatelet medications inhibit platelet activation, aggregation, and other pathways eventually inhibiting clot formation. Aspirin and clopidogrel have been the mainstay in the management of acute coronary syndrome for about a decade. We have discussed the role of aspirin, clopidogrel, ticagrelor, and prasugrel which are the most commonly used oral antiplatelet medications in the current era. We have also considered the role of newer thrombin inhibitor vorapaxar, and dual antiplatelet therapy. In this review paper, we have summarized the continuing controversy about the use of oral antiplatelet therapy and their role in primary as well as secondary prevention of MI by describing results from major clinical trials. The safety and the efficacy of the above medications have been reviewed and described in this paper.

Longer-term oral antiplatelet use in stable post-myocardial infarction patients: Insights from the long Term rIsk, clinical manaGement and healthcare Resource utilization of stable coronary artery dISease (TIGRIS) observational study

ObjectiveTo describe contemporary patient characteristics and treatment patterns, including antithrombotic management, of post-myocardial infarction (MI) stable coronary artery disease (CAD) patients at high atherothrombotic risk from different geographical regions. MethodsPatients ≥50years with prior MI 1–3years ago and ≥1 risk factor (age ≥65years, diabetes, 2nd prior MI >1yr ago, multivessel CAD, creatinine clearance 15–<60ml/min) were enrolled by 369 physicians (96% cardiologists) in 25 countries (2013–14) in the prospective TIGRIS study (NCT01866904). Results9225 patients were enrolled (median 1.8years) post-MI: 52% with prior ST-elevation MI, median age 67years, 24% women, 67% Caucasian, 55% had ≥2 additional qualifying risk factors, 14% current smokers, 67% overweight/obese, 34% with blood pressure ≥140/90mmHg. 81% underwent percutaneous coronary intervention (PCI; 66% with drug-eluting stents) for the index MI. 75% of patients had been discharged on dual antiplatelet therapy (DAPT; acetylsalicylic acid [ASA]+ADP receptor inhibitor [ADPri]), mainly clopidogrel (75%). 63% had discontinued antiplatelet treatment (60% ADPri) around 1year, most commonly by physician recommendation (90%). At enrolment, 97% were taking an antithrombotic drug, most commonly ASA (88%), with 27% on DAPT (median duration 1.6years); continued DAPT >1year was highest (39%) in Asia-Pacific and lowest (12%) in Europe. ConclusionsDespite guideline recommendations, 1 in 4 post-MI patients did not receive DAPT for ~1year. In contrast to guideline recommendations supporting newer ADPris, clopidogrel was mainly prescribed. Prior to recent RCT data supporting DAPT >1year post-MI/PCI, >1 in 4 patients have continued on DAPT, though with substantial international variability.

Key Advances in Clinical Cardiology

Multiple key cardiology trials with the potential to change practice or advance understanding have been presented over the past 12 months at international meetings, including the American College of Cardiology (ACC, Chicago, USA, March 2012), European Association for Percutaneous Cardiovascular Interventions (EuroPCR, Paris, France, May 2012), European Society of Cardiology (ESC, Munich, Germany, August 2012), Transcatheter Cardiovascular Therapeutics (TCT, Miami, USA, October 2012), and the American Heart Association (AHA, Los Angeles, USA, November 2012). In this paper, the authors describe and place in clinical context new acute coronary syndrome data, including use of oral antiplatelets and anticoagulants (prasugrel, rivaroxaban, vorapaxar), personalized antiplatelet therapy guided by platelet aggregometry, glucose-insulin-potassium infusion, and changing trends in myocardial infarction. New trial data are also described for interventional cardiology (revascularization in multivessel disease, fractional flow reserve-guided intervention, radial access, bioabsorbable polymer stents, drug-eluting balloons, intraaortic balloon pump use, transcatheter aortic valve implantation), in heart failure (copeptin, angiotensin receptor neprilysin inhibition, aldosterone blockade in diastolic heart failure, biventricular pacing), atrial fibrillation (surgical ablation, antithrombotic strategy after stenting), implantable defibrillator use, and in prevention (renal denervation in hypertension, dalcetrapib, lomitapide, proprotein convertase subtilisin/kexin type 9 in dyslipidemia, insulin glargine/fish oils, and bariatric surgery in diabetes).

Abstract 4007: Association between Post-discharge Oral Antiplatelet Use and Clinical Outcomes among US Patients Hospitalized for Transient Ischemic Attack or Stroke

Background: More than 800,000 Americans have a stroke or transient ischemic attack (TIA) each year. Antiplatelets are recommended to reduce the risk of recurrence and other clinical events. Conflicting data exist regarding the relative efficacy of two common oral antiplatelets (OAPs): aspirin plus extended-release dipyridamole (ASA-ERDP) and clopidogrel (CLO). Objective: To examine clinical outcomes using real-world data among patients hospitalized for TIA or stroke and initially prescribed ASA-ERDP or CLO post-discharge. Methods: This retrospective claims study from a US commercial and Medicare health plan analyzed adults who had at least one hospitalization for TIA or stroke between 01/2007 and 07/2009 and at least one pharmacy claim for an OAP within 30 days of discharge. Patients were observed for one year before and after the first hospitalization or until death. Post-discharge outcomes included vascular events, clinically relevant bleeds, and all-cause death. The composite and individual outcome measures were modeled using logistic multivariate (MV) regression, adjusting for baseline demographics, comorbidities, costs, and initial OAP use. Results: In total, 6,377 subjects (2,085 ASA-ERDP; 4,292 CLO) met the inclusion criteria. ASA-ERDP had a lower unadjusted proportion with the composite endpoint than CLO (19.1% vs. 22.0%, respectively; p=0.01). Significant unadjusted outcomes in the composite were: CHF (8.1% vs. 10.8%; p&lt;0.001), MI (2.4% vs. 4.0%; p=0.001), GI bleeds (3.5% vs. 4.7%; p=0.03), and other hemorrhagic events (2.0% vs. 3.0%; p=0.02). Unadjusted stroke/TIA readmission was not significant (9.1% vs. 9.0%; p=0.95). MV modeling indicated age, comorbidities, index stroke/TIA event, and baseline costs as significant risk factors associated with the composite endpoint. Compared to CLO, the initial use of ASA-ERDP post-discharge was associated with 15% lower risk in the composite endpoint (OR = 0.85; p=0.03), but GI bleeding was the only significant individual component (OR=0.56; p=0.003). Conclusion: This study suggests that in the year following discharge for TIA or stroke, patients who received ASA-ERDP had a lower likelihood of the composite endpoint, due partly to GI bleeding, than patients who received CLO.