International patterns of dual antiplatelet therapy duration after acute coronary syndromes

Héctor Bueno, Stuart Pocock, Nicolas Danchin, Lieven Annemans, John Gregson, Jesús Medina, Frans Van de Werf, Héctor Bueno, Stuart Pocock, Nicolas Danchin, Lieven Annemans, John Gregson, Jesús Medina, Frans Van de Werf

Abstract

Objective: To describe international patterns of dual antiplatelet therapy (DAPT) duration after acute coronary syndrome (ACS), and explore its determinants and correlation with clinical events.

Methods: EPICOR (long-tErm follow-uP of anti-thrombotic management patterns In acute CORonary syndrome patients) is a prospective, international, observational study of 10 568 ACS hospital survivors enrolled in 555 centres from 20 countries across Europe and Latin America between 2010 and 2011, with telephone follow-up at quarterly intervals up to 24 months to assess treatment continuation and clinical events.

Results: Of 8593 patients discharged on DAPT, 4859 (57%) remained on uninterrupted DAPT at end of follow-up. There were minor differences in rates of DAPT discontinuation according to age, gender, risk factors, therapeutic strategy or region, but major differences between countries. By study end, 555 of evaluable patients (5.7%) died, 727 (10.0%) experienced new cardiovascular (CV) events, 496 new coronary events (6.82%) and 154 (2.11%) clinically relevant bleeding (14 (6.7%) fatal). Most CV events and deaths (85%) occurred while on DAPT. DAPT interruption was associated with increased risk of CV events in the following week (HR 2.29; 95% CI 1.08 to 4.84) but not specifically with time to first coronary event or mortality.

Conclusions: Despite guideline recommendations, most patients with ACS in Europe and Latin America remained on DAPT beyond 12 months, country being the most important determinant of DAPT duration. Increase in short-term CV risk was seen after switching from DAPT to less medication, as compared with continued DAPT, with no long-term effect on coronary or mortality risk.

Trial registration number: NCT01171404; Results.

Conflict of interest statement

HB has received advisory/consulting fees from Abbott, AstraZeneca, Bayer, BMS-Pfizer, Daichii-Sankyo, Eli-Lilly, Ferrer, Menarini, Novartis, Sanofi and Servier, and research grants from AstraZeneca. SP has received research funding from AstraZeneca. ND has received research grants from Amgen, AstraZeneca, Bayer, Daiichi-Sankyo, Eli-Lilly, MSD and Sanofi, and consulting or speaking fees from Amgen, AstraZeneca, Bayer, BMS, Boehringer-Ingelheim, GSK, MSD-Schering Plough, Novartis, Pierre Fabre, Pfizer, Roche, Sanofi-Aventis, Servier and The Medicines Company. LA has received consulting and lecture fees from AstraZeneca. JM is an employee of AstraZeneca. JG has received research funding from AstraZeneca. FVdW has received consulting fees and research grants from Boehringer-Ingelheim and Merck, and consulting fees from Roche, Sanofi-Aventis, AstraZeneca and The Medicines Company.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Figures

Figure 1
Figure 1
Changes in medication status during follow-up among patients with ACS discharged on DAPT. ACS, acute coronary syndrome; DAPT, dual antiplatelet therapy; FU, follow-up.
Figure 2
Figure 2
Proportion of patients on DAPT at the end of follow-up by country. This analysis excluded patients who died or were lost to follow-up. DAPT, dual antiplatelet therapy.
Figure 3
Figure 3
Risk of CV or coronary events following interruption of DAPT versus remaining on DAPT. CV, cardiovascular; DAPT, dual antiplatelet therapy.

References

    1. Mauri L, Kereiakes DJ, Yeh RW, et al. . Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med 2014;371:2155–66. 10.1056/NEJMoa1409312
    1. Yusuf S, Zhao F, Mehta SR, et al. . Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001;345:494–502. 10.1056/NEJMoa010746
    1. Wiviott SD, Braunwald E, McCabe CH, et al. . Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007;357:2001–15. 10.1056/NEJMoa0706482
    1. Wallentin L, Becker RC, Budaj A, et al. . Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045–57. 10.1056/NEJMoa0904327
    1. Hamm CW, Bassand JP, Agewall S, et al. . ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. 10.1093/eurheartj/ehr236
    1. Steg PG, James SK, Atar D, et al. . ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569–619. 10.1093/eurheartj/ehs215
    1. Mulukutla SR, Marroquin OC, Vlachos HA, et al. . Benefit of long-term dual anti-platelet therapy in patients treated with drug-eluting stents: from the NHLBI dynamic registry. Am J Cardiol 2013;111:486–92. 10.1016/j.amjcard.2012.10.030
    1. Mehran R, Baber U, Steg PG, et al. . Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet 2013;382:1714–22. 10.1016/S0140-6736(13)61720-1
    1. Schiele F, Puymirat E, Bonello L, et al. . Impact of prolonged dual antiplatelet therapy after acute myocardial infarction on 5-year mortality in the FAST-MI 2005 registry. Int J Cardiol 2015;187:354–60. 10.1016/j.ijcard.2015.03.333
    1. Bueno H, Danchin N, Tafalla M, et al. . EPICOR (long-tErm follow-up of antithrombotic management Patterns In acute CORonary syndrome patients) study: rationale, design, and baseline characteristics. Am Heart J 2013;165:8–14. 10.1016/j.ahj.2012.10.018
    1. Bueno H, Sinnaeve P, Annemans L, et al. . Opportunities for improvement in anti-thrombotic therapy and other strategies for the management of acute coronary syndromes: Insights from EPICOR, an international study of current practice patterns. Eur Heart J Acute Cardiovasc Care 2016;5:3–12. 10.1177/2048872614565912
    1. Altman DG, De Stavola BL. Practical problems in fitting a proportional hazards model to data with updated measurements of the covariates. Stat Med 1994;13:301–41. 10.1002/sim.4780130402
    1. Roffi M, Patrono C, Collet JP, et al. . 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37:267–315. 10.1093/eurheartj/ehv320
    1. Bonaca MP, Bhatt DL, Cohen M, et al. . Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med 2015;372:1791–800. 10.1056/NEJMoa1500857
    1. Garratt KN, Weaver WD, Jenkins RG, et al. . Prasugrel plus aspirin beyond 12 months is associated with improved outcomes after taxus liberte Paclitaxel-eluting coronary stent placement. Circulation 2015;131:62–73. 10.1161/CIRCULATIONAHA.114.013570
    1. Palmerini T, Benedetto U, Bacchi-Reggiani L, et al. . Mortality in patients treated with extended duration dual antiplatelet therapy after drug-eluting stent implantation: a pairwise and Bayesian network meta-analysis of randomised trials. Lancet 2015;385:2371–82. 10.1016/S0140-6736(15)60263-X
    1. Navarese EP, Andreotti F, Schulze V, et al. . Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug eluting stents: meta-analysis of randomised controlled trials. BMJ 2015;350:h1618 10.1136/bmj.h1618
    1. Udell JA, Bonaca MP, Collet JP, et al. . Long-term dual antiplatelet therapy for secondary prevention of cardiovascular events in the subgroup of patients with previous myocardial infarction: a collaborative meta-analysis of randomized trials. Eur Heart J 2016;37:390–9. 10.1093/eurheartj/ehv443

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