Feasibility and outcomes of tailored antiplatelet therapy at a safety-net hospital

Background Antithrombotic therapy with a P2Y12 inhibitor ± aspirin/oral anticoagulant after percutaneous coronary intervention (PCI) is critical to prevent stent thrombosis. The three oral P2Y12 inhibitors vary in potency, bleed risk, dosing regimen, place in guideline recommendations, and cost. Known disparities in access to medications, adherence, and use of first-line agents among minority groups increase the risk of stent thrombosis and recurrent MI after PCI. At our large, urban, safety-net hospital, the majority of the patients that we serve are uninsured or underinsured and belong to minority groups that are vulnerable to factors that reduce medication adherence. In order to provide equitable care, we implemented interventions aimed at improving adherence by making care both accessible and acceptable for patients’ individual circumstance. Purpose To compare one-year ischemic and bleeding outcomes after percutaneous coronary intervention between clopidogrel responders and non-responders treated with ticagrelor or prasugrel as part of a tailored antiplatelet strategy. Methods In this quality improvement project, adults underwent platelet function testing (PFT) after clopidogrel initiation for ACS and/or PCI and were classified as responders (ADP inhibition <40% on light transmission aggregometry) or non-responders. Responders remained on clopidogrel and non-responders were switched to ticagrelor or prasugrel. The primary outcome was a one-year composite of stent thrombosis, cardiac death, and bleeding. Concurrently, all PCI patients received at least a 30-day supply of antithrombotic therapy via bedside delivery and a follow-up call to support adherence during the period of greatest thrombotic risk. Results As part of the guided antiplatelet program, 455 patients (mean age 64.9 years, 32% women, 90% non-White) were followed for one year to assess differences in outcomes between clopidogrel responders and non-responders that were switched to another agent. No differences were observed in the primary outcome (composite of stent thrombosis, cardiac death, and bleeding events) at one year (7% vs 6%, log-rank p=0.67) between the groups, nor were there differences in the individual components of the primary outcome. In the Meds-to-Beds program, a 95% (1175/1243) delivery rate was achieved over two years, where previously no bedside delivery option existed. Conclusion The use of clopidogrel in patients confirmed to be responders was as safe and effective as ticagrelor or prasugrel at one year. Clopidogrel remains widely used and its advantages (once-daily dosing, lower bleed risk, and lower cost) make it a viable option despite guideline preference for ticagrelor and prasugrel. Combining tailored therapy with bedside medication delivery can reduce costs and expand the ability to provide optimal post-PCI care in vulnerable populations.