High-Potency P2Y12 Inhibitors Among Patients With Chronic Coronary Syndrome Undergoing PCI: An Analysis From the NCDR CathPCI Registry

BACKGROUND: Clinical practice guidelines recommend the use of clopidogrel among patients with chronic coronary syndrome undergoing percutaneous coronary intervention. The frequency of high-potency P2Y12 inhibitors, such as ticagrelor or prasugrel, in this setting is not well known. METHODS: Using the National Cardiovascular Data Registry CathPCI registry, we analyzed patients with chronic coronary syndrome undergoing percutaneous coronary intervention from April 2018 to June 2024, excluding those discharged on oral anticoagulants. Temporal trends in high-potency P2Y12 inhibitor prescription were examined. A mixed-effects multivariable logistic regression model with a random intercept for hospital was used to identify patient-, procedural-, and institutional-level factors associated with high-potency P2Y12 inhibitor prescription while accounting for within-hospital clustering. Between-hospital variation was quantified using the median odds ratio. RESULTS: -trend=0.10). Male sex, prior myocardial infarction, and markers of procedural complexity (high-complexity/type C lesions, left main coronary artery, proximal left anterior descending artery, or use of mechanical circulatory support) were associated with higher odds of high-potency P2Y12 inhibitor prescription. In contrast, older age (≥75 years), prior stroke/transient ischemic attack, prior coronary artery bypass graft, severe renal dysfunction, and chronic total occlusion were associated with lower odds. University hospitals had lower odds of prescribing high-potency P2Y12 inhibitors, with considerable variability in prescription patterns among institutions (median odds ratio, 2.59). CONCLUSIONS: Nearly one-third of chronic coronary syndrome patients undergoing percutaneous coronary intervention were discharged on high-potency P2Y12 inhibitors, with decreasing trends over time. Practice patterns reflected perceived ischemic versus bleeding risk and significant institutional variation, underscoring opportunities for quality improvement and guideline alignment.