Comparative effectiveness and safety of antiplatelet drugs in patients with diabetes mellitus and acute coronary syndrome
Comparative effectiveness and safety of antiplatelet drugs in patients with diabetes mellitus and acute coronary syndrome
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DOI：
10.1002/pds.4668
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发表时间：
2018-12-01
影响因子：
2.6
通讯作者：
Desai, Rishi J.
中科院分区：
文献类型：
--
作者：
Spoendlin, Julia;Gagne, Joshua J.;Desai, Rishi J.
目的 急性冠脉综合征 (ACS) 和共病糖尿病 (DM) 患者抗血小板药物治疗的比较结果尚未得到充分研究。方法我们使用美国商业索赔数据（2009-2015）进行了一项队列研究，并对合并 DM 的 ACS 患者进行了以下配对比较：普拉格雷与氯吡格雷、替格瑞洛与氯吡格雷以及普拉格雷与替格瑞洛。感兴趣的结果包括（1）复合有效性终点，包括心肌梗死、缺血性中风或住院患者死亡率； (2) 复合安全终点，包括需要住院治疗的大出血事件； (3) 肺炎住院作为阴性对照终点。我们使用日历时间特定倾向得分匹配来解释混杂因素，并应用 Cox 比例风险模型来计算具有 95% 置信区间 (CI) 的风险比 (HR)。结果 与氯吡格雷起始剂相比，普拉格雷起始剂的有效性终点比较风险较低（HR 0.82，95% CI 0.68-0.99，N = 7011 配对），但替格瑞洛和氯吡格雷（HR 1.02，95% CI 0.76-1.37，N = 3013 对）或普拉格雷之间没有差异和替格瑞洛 （HR 0.83，95% CI 0.58-1.18，N = 2207 对）。治疗第一个月内，普拉格雷起始剂的出血风险高于氯吡格雷起始剂（HR 1.85，95% CI 1.03-3.35）；没有其他比较表明有任何差异。所有比较的 PS 匹配后，阴性对照结果均未发现差异，表明有足够的混杂控制。结论 与氯吡格雷相比，对于 ACS 和 DM 患者，普拉格雷与更好的心血管结局和更高的短期出血风险相关。替格瑞洛和氯吡格雷或普拉格雷和替格瑞洛之间的比较结果相似。
Purpose Comparative outcomes of treatment with antiplatelet drugs in patients with acute coronary syndrome (ACS) and co-morbid diabetes mellitus (DM) are not well studied. Methods We performed a cohort study using US commercial claims data (2009-2015) and conducted the following pairwise comparisons in ACS patients with DM: prasugrel vs clopidogrel, ticagrelor vs clopidogrel, and prasugrel vs ticagrelor. Outcomes of interest included (1) a composite effectiveness endpoint including myocardial infarction, ischemic stroke, or inpatient mortality; (2) a composite safety endpoint including major bleeding events requiring hospitalization; and (3) pneumonia hospitalizations as a negative control endpoint. We used calendar time-specific propensity score matching to account for confounding and applied Cox proportional hazard models to calculate hazard ratios (HR) with 95% confidence intervals (CI). Results Comparative risk of the effectiveness endpoint was lower among prasugrel initiators compared to clopidogrel initiators (HR 0.82, 95% CI 0.68-0.99, N = 7011 matched pairs), but no different between ticagrelor and clopidogrel (HR 1.02, 95% CI 0.76-1.37, N = 3013 pairs) or prasugrel and ticagrelor (HR 0.83, 95% CI 0.58-1.18, N = 2207 pairs). Bleeding risk was higher among prasugrel initiators when compared to clopidogrel initiators within the first month of treatment (HR 1.85, 95% CI 1.03-3.35); no other comparison indicated any difference. No differences in the negative control outcomes were noted after PS matching for all comparisons, indicating adequate confounding control. Conclusions Prasugrel was associated with superior cardiovascular outcomes and a higher risk of short-term bleeding compared to clopidogrel in patients with ACS and DM. Comparative outcomes were similar between ticagrelor and clopidogrel or prasugrel and ticagrelor.