Use of Prasugrel and Ticagrelor in Stable Ischemic Heart Disease After Percutaneous Coronary Intervention, 2009–2016

heart diseases ◼ percutaneous coronary intervention ◼ ticagrelor P rasugrel and ticagrelor have demonstrated improved cardiovascular outcomes over clopidogrel in patients with acute coronary syndrome (ACS), 1 and guidelines recommend prasugrel and ticagrelor in preference to clopidogrel in ACS patients treated with percutaneous coronary intervention (PCI).Conversely, for patients with stable ischemic heart disease (SIHD) treated with PCI, guidelines recommend clopidogrel, the only P2Y 12 inhibitor with Class I evidence in PCI patients with SIHD. 1 Nonetheless, a potential benefit of prasugrel and ticagrelor for SIHD has been suggested by pharmacodynamics studies of low-risk patients, 2 thus potentially motivating some clinicians to use these medications off-label.The frequency of off-label ticagrelor and prasugrel use in SIHD remains unknown.We, therefore, assessed trends in P2Y 12 inhibitor use after PCI for patients with SIHD from years 2009 to 2016, spanning the period in which prasugrel and ticagrelor were introduced.Data were obtained from OptumInsight Clinformatics Data Mart, a US commercial health insurance database with >15 million enrollees annually.Using administrative claims from January 1, 2009, to December 1, 2016, we included patients aged 18 to 64 years who underwent PCI and who subsequently filled a P2Y 12 inhibitor prescription.PCI was identified using Internal Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes 36.0x, and 00.66 or Internal Classification of Diseases, Tenth Revision, Procedural Coding System (ICD-10-PCS) codes 02703xx, 02713xx, 02723xx, and 02733xx (except 027x3Tx and 027x3Zx), and diagnosis-related group codes 246, 247, 248, and 249.ACS was identified using ICD-9-CM diagnosis codes 410.xx, 411.1, 411.8x or ICD-10-CM diagnosis codes I21.xx, I22.xx, I24.xx, I25.110, and I25.7x0.The cohort was restricted to patients with continuous health insurance enrollment for at least 90 days before and at least 30 days following the PCI hospitalization.Pharmacy claims identified the specific P2Y 12 inhibitor filled within 30 days of discharge from PCI hospitalization.To ensure the cohort was restricted to P2Y 12 -naïve patients, we excluded patients with prior P2Y 12 inhibitor prescriptions during the 90 days preceding PCI.The primary outcome was the percentage of non-ACS and ACS patients filling each P2Y 12 inhibitor, by year of the index PCI.Analyses were performed using Stata, version 15 (StataCorp).We identified 42 683 patients who filled a prescription for clopidogrel, ticagrelor, or prasugrel within 30 days of PCI from years 2009 to 2016.Of those patients, 6959 had a non-ACS indication for PCI (16%) and 35 724 had ACS as the indication for PCI (84%).During the study period, the proportion of non-ACS PCI patients filling clopidogrel decreased from 99% to 66%, while the proportion of patients filling a prescription for prasugrel or ticagrelor increased from 1.0% to 34%.For patients with ACS, the proportion of filling clopidogrel after PCI decreased from 98% to 52%, while the proportion filling prasugrel or ticagrelor increased from 2.0% to 48% (Figure).