Comparative Effectiveness and Safety Analysis of Dual Antiplatelet Therapies Within an Integrated Delivery System

• Published in: The Annals of pharmacotherapy 2017-08, Vol.51 (8), p.649-655
• Main Authors: Coons, James C., Iasella, Carlo J., Chanas, Tyler, Wang, Nan, Williams, Kiersten, Boyd, Anthony, Lyons, John, Eckardt, Jamie, Rihtarchik, Lindsey, Merkel, Alison, Chambers, Alexandra, Lemon, Lara S., Smith, Randall, Ensor, Christopher R.
• Format: Article
• Language: English
• Subjects: Acute Coronary Syndrome - blood; Acute Coronary Syndrome - surgery; Adenosine - administration & dosage; Adenosine - adverse effects; Adenosine - analogs & derivatives; Adenosine - therapeutic use; Aged; Delivery of Health Care, Integrated; Female; Hemorrhage - chemically induced; Humans; Male; Middle Aged; Odds Ratio; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors - administration & dosage; Platelet Aggregation Inhibitors - adverse effects; Platelet Aggregation Inhibitors - therapeutic use; Prasugrel Hydrochloride - administration & dosage; Prasugrel Hydrochloride - adverse effects; Prasugrel Hydrochloride - therapeutic use; Propensity Score; Proportional Hazards Models; Purinergic P2Y Receptor Antagonists - administration & dosage; Purinergic P2Y Receptor Antagonists - adverse effects; Purinergic P2Y Receptor Antagonists - therapeutic use; Receptors, Purinergic P2Y12 - metabolism; Retrospective Studies; Safety; Ticlopidine - administration & dosage; Ticlopidine - adverse effects; Ticlopidine - analogs & derivatives; Ticlopidine - therapeutic use
• ISSN: 1060-0280; 1542-6270
• DOI: 10.1177/1060028017706977

Background: Dual antiplatelet therapy is a mainstay of care for percutaneous coronary intervention (PCI) patients; however, uncertainty exists in real-world practice about comparative effectiveness and safety outcomes. Objective: To evaluate outcomes of different oral P2Y12 inhibitors in PCI patients. Methods: We retrospectively studied patients treated between July 1, 2010, and December 31, 2013. Patients received clopidogrel, prasugrel, ticagrelor, or more than 1 antiplatelet (switch) during PCI. Outcomes were evaluated for major adverse cardiovascular events (MACE) and bleeding at 1 year. Propensity score matching with Cox proportional hazards analysis was used to determine predictors of MACE and bleeding. Results: A total of 8127 patients were included: clopidogrel (n = 6872), prasugrel (n = 605), ticagrelor (n = 181), and switch (n = 469). Treatment with prasugrel was associated with the lowest risk of MACE using multivariate regression (odds ratio [OR] = 0.57; 95% CI = 0.36-0.92; P = 0.02). In the propensity score–matched analysis, only the prasugrel group was associated with a lower risk of MACE compared with the clopidogrel group. Clopidogrel was associated with the lowest risk of major bleeding using multivariate regression (OR = 0.64; 95% CI = 0.42-0.98; P = 0.042). Both ticagrelor (hazard ratio [HR] = 2.00; 95% CI = 1.11-3.59) and the switch groups (HR = 1.65; 95% CI = 1.09-2.50) were associated with a greater risk of major bleeding compared with clopidogrel. However, no differences were found in the propensity score–matched analysis. Conclusions: Dual antiplatelet therapies differed in both MACE and bleeds in a real-world setting of PCI. Prasugrel was associated with fewer MACE, whereas clopidogrel had fewer major bleeding events.