Potent P2Y12 inhibitors versus clopidogrel to predict adherence to antiplatelet therapy after an acute coronary syndrome: insights from IDEAL-LDL

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Acute coronary syndrome (n=344). Intervention: Potent P2Y12 inhibitors (ticagrelor or prasugrel) vs. Clopidogrel. Primary outcome: Adherence to the prescribed P2Y12 inhibitor (Proportion of Days Covered ≥ 80%) throughout the first 12 months of DAPT (OR 0.98, 95% CI 0.55-1.74, p=0.943).

Olga Kourti; Orestis Konstantas; Ioannis T. Farmakis; Stefanos Zafeiropoulos; Georgios Psarakis; Eleni Vrana; Amalia Baroutidou; Spyridon Graidis; Aikaterini Vasiliki Touriki; Christos Tsolakidis; Konstantina Spyridaki; Thomas Psathas; Anastasia Daniilidou; Haralambos Karvounis; George Giannakoulas

doi:10.31083/j.rcm2303081

March 3, 2022Reviews in Cardiovascular MedicineOpen Access

Potent P2Y12 inhibitors versus clopidogrel to predict adherence to antiplatelet therapy after an acute coronary syndrome: insights from IDEAL-LDL

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Key result

Adherence to dual antiplatelet therapy during the first year after an acute coronary syndrome was not affected by the potency of the prescribed P2Y12 inhibitor.

Why the study?

Potent P2Y12 inhibitors cause more adverse events than clopidogrel after ACS, which may influence patient adherence to prescribed dual antiplatelet therapy.

Does potent P2Y12 inhibitor therapy improve adherence to antiplatelet therapy compared to clopidogrel in patients after an acute coronary syndrome?

Key Points

To assess adherence differences between potent P2Y12 inhibitors and clopidogrel, alongside clinical predictors of adherence, in patients prescribed dual antiplatelet therapy after acute coronary syndrome.
Analyzed 344 patients discharged on dual antiplatelet therapy following acute coronary syndrome within an IDEAL-LDL randomized trial substudy (NCT02927808).
Evaluated primary adherence between potent P2Y12 inhibitors and clopidogrel adjusting for regimen switching, and identified predictors of dual antiplatelet therapy continuation beyond 12 months.
Adherence did not differ between potent P2Y12 inhibitors and clopidogrel after adjusting for therapy switching during the first year (OR = 0.98, 95% CI = 0.55–1.74).
Prior cardiovascular disease reduced adherence (OR = 0.51, 95% CI = 0.31–0.86), whereas percutaneous coronary intervention during the index event increased adherence (OR = 2.58, 95% CI = 1.38–4.82).
Dual antiplatelet therapy was continued beyond 12 months in 72% of patients, with female sex negatively predicting prolonged therapy (adjusted OR = 0.43, 95% CI = 0.21–0.90).

Study Design

Type

Observational (n=344)

Multicenter

No

Structured PICO

Does potent P2Y12 inhibitor therapy improve adherence to antiplatelet therapy compared to clopidogrel in patients after an acute coronary syndrome?

P

Population

344 patients (median age 60, 18.9% female) with acute coronary syndrome discharged on dual antiplatelet therapy from a single center in Greece, evaluated for 12-month medication adherence.

E

Exposure

Potent P2Y12 inhibitors (ticagrelor or prasugrel) combined with concomitant aspirin therapy or oral anticoagulant

C

Comparator

Clopidogrel combined with concomitant aspirin therapy or oral anticoagulant

O

Outcome

Difference between potent P2Y12 inhibitors and clopidogrel in terms of adherence to treatment (measured by Proportion of Days Covered ≥80% throughout the first 12 months of DAPT), and predictors of adherence

Main Result

Odds Ratio: 0.98 (95% CI 0.55–1.74)

Absolute Event Rate: 78.7% vs 66.9%

p-value: p=0.943

Adherence to dual antiplatelet therapy after an acute coronary syndrome is not significantly affected by the potency of the P2Y12 inhibitor prescribed, but rather by patient history and index event treatment.

Limitations

Small sample size
Selection bias as not every consecutive patient was included
Adherence to aspirin was difficult to obtain through the national prescription system
Discontinuation rates due to specific adverse events or physician's choice were not recorded
Low rates of prasugrel use limit generalizability for that specific drug
Single-center observational design
Single-centre study
All patients receiving a potent P2Y12 inhibitor were grouped together
Standard DAPT duration of 12 months may not be the optimal duration for all ACS patients

Ask about this paper

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Implication

Need not withhold potent P2Y12i solely over adherence; challenges the adverse-event hypothesis and leaves open switching as the driver.

Abstract

BACKGROUND: Superiority of potent P2Y12 inhibitors over clopidogrel after an acute coronary syndrome (ACS) has been well established, however potent P2Y12 inhibition is responsible for more adverse events, which may influence patient adherence to treatment. Aim of the present study is to investigate the adherence to the prescribed P2Y12 inhibitor (P2Y12i) in patients on dual antiplatelet therapy (DAPT) after an ACS. METHODS: In an IDEAL-LDL trial substudy, we included 344 patients after ACS discharged on DAPT. The primary outcome was the difference between potent P2Y12i and clopidogrel in terms of adherence, as well as other predictors of adherence to the antiplatelet regimen. Secondary outcomes included the prevalence of DAPT continuation and its predictors and the antiplatelet regimen selection after DAPT. In the multivariate model, after adjustment for P2Y12i switching during the first year of therapy, there was no difference observed in adherence between potent P2Y12i and clopidogrel (odds ratio [OR] = 0.98, 95% confidence interval [CI] = 0.55-1.74). Significant predictors included history of cardiovascular disease (CVD) (OR = 0.51, 95% CI = 0.31-0.86) and percutaneous coronary intervention (PCI) index event treatment (OR = 2.58, 95% CI = 1.38-4.82). Of patients, 72% continued DAPT >12 months and female gender was a negative predictor of DAPT prolongation (adjusted OR = 0.43, 95% CI = 0.21-0.90). DAPT was continued until the end of follow-up in 42.7%, while 54.6% resumed with single antiplatelet regimen. CONCLUSIONS: Adherence to DAPT was not affected by the P2Y12i potency, whereas history of CVD and PCI treatment were associated with reduced and increased adherence, respectively. CLINICAL TRIAL REGISTRATION: NCT02927808, https://clinicaltrials.gov/ct2/show/NCT02927808.

Discussion

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Cite This Study

Kourti et al. (2022) conducted an observational in Acute coronary syndrome (n=344). Potent P2Y12 inhibitors (ticagrelor or prasugrel) vs. Clopidogrel was evaluated on Adherence to the prescribed P2Y12 inhibitor (Proportion of Days Covered ≥ 80%) throughout the first 12 months of DAPT (OR 0.98, 95% CI 0.55-1.74, p=0.943). Adherence to dual antiplatelet therapy during the first year after an acute coronary syndrome was not affected by the potency of the prescribed P2Y12 inhibitor.

synapsesocial.com/papers/6a7eecb480d715b4559c4362 https://doi.org/10.31083/j.rcm2303081

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Potent P2Y12 inhibitors versus clopidogrel to predict adherence to antiplatelet therapy after an acute coronary syndrome: insights from IDEAL-LDL

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Potent P2Y12 inhibitors versus clopidogrel to predict adherence to antiplatelet therapy after an acute coronary syndrome: insights from IDEAL-LDL

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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