Key result
Early clopidogrel discontinuation post-MI is linked to a ~162% increased risk of death or MI.
Why the study?
Adherence to evidence-based treatments and its consequences after acute MI were poorly defined.
Does discontinuation of clopidogrel increase the risk of death or non-fatal MI in patients discharged after acute myocardial infarction?
Cohort (n=7,543)
Yes
Does discontinuation of clopidogrel increase the risk of death or non-fatal MI in patients discharged after acute myocardial infarction?
Premature discontinuation of clopidogrel within 12 months after MI is common in primary care and is strongly associated with an increased risk of death or recurrent MI.
Answers are grounded in this paper and cite their sources.
Discontinuation of clopidogrel after MI was associated with higher death or recurrent MI risk; extends observational data but leaves open causal effects and adherence interventions.
AIMS: Adherence to evidence-based treatments and its consequences after acute myocardial infarction (MI) are poorly defined. We examined the extent to which clopidogrel treatment initiated in hospital is continued in primary care; the factors predictive of clopidogrel discontinuation and the hazard of death or recurrent MI. METHODS AND RESULTS: We linked the Myocardial Ischaemia National Audit Project registry and the General Practice Research Database to examine adherence to clopidogrel in primary care among patients discharged from hospital after MI (2003-2009). Hospital Episode Statistics and national mortality data were linked, documenting all-cause mortality and non-fatal MI. Of the 7543 linked patients, 4650 were prescribed clopidogrel in primary care within 3 months of discharge. The adjusted odds of still being prescribed clopidogrel at 12 months were similar following non-ST-elevation myocardial infarction (NSTEMI) 53% (95% CI, 51-55) and ST-elevation myocardial infarction (STEMI) 54% (95% CI, 52-56), but contrast with statins: NSTEMI 84% (95% CI, 82-85) and STEMI 89% (95% CI, 87-90). Discontinuation within 12 months was more frequent in older patients [>80 vs. 40-49 years, adjusted hazard ratio (HR) 1.50 (95% CI, 1.15-1.94)] and with bleeding events [HR 1.34 (95% CI, 1.03-1.73)]. 18.15 patients per 100 person-years (95% CI, 16.83-19.58) died or experienced non-fatal MI in the first year following discharge. In patients who discontinued clopidogrel within 12 months, the adjusted HR for death or non-fatal MI was 1.45 (95% CI, 1.22-1.73) compared with untreated patients, and 2.62 (95% CI, 2.17-3.17) compared with patients persisting with clopidogrel treatment. CONCLUSION: This is the first study to use linked registries to determine persistence of clopidogrel treatment after MI in primary care. It demonstrates that discontinuation is common and associated with adverse outcomes.
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Boggon et al. (2011) conducted a cohort in Acute myocardial infarction (NSTEMI and STEMI) (n=7,543). Clopidogrel discontinuation vs. Persistence with clopidogrel treatment was evaluated on Death or non-fatal MI (HR 2.62, 95% CI 2.17-3.17). Discontinuation of clopidogrel within 12 months of discharge after acute myocardial infarction was associated with a increased risk of death or non-fatal MI compared with persisting treatment.
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