Assessing the Clinical Treatment Dynamics of Antiplatelet Therapy Following Acute Coronary Syndrome and Percutaneous Coronary Intervention in the US.
Assessing the Clinical Treatment Dynamics of Antiplatelet Therapy Following Acute Coronary Syndrome and Percutaneous Coronary Intervention in the US.
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评估美国急性冠状动脉综合征和经皮冠状动脉介入治疗后抗血小板治疗的临床治疗动态。
DOI：
10.1001/jamanetworkopen.2023.8585
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发表时间：
2023-04-03
影响因子：
13.8
通讯作者：
Winterstein, Almut G.
中科院分区：
文献类型：
--
作者：
Wang, Yehua;Cavallari, Larisa H.;Brown, Joshua D.;Thomas, Cameron D.;Winterstein, Almut G.
血小板ADP P2 Y12受体（P2 Y12）抑制剂的治疗动力学以及影响急性冠状动脉综合征和经皮冠状动脉介入治疗后初始选择和转换的因素是什么？在这项2010年至2019年的62423例患者的队列研究中，从替格瑞洛（2019年处方的主要初始P2 Y12抑制剂）或普拉格雷转换为氯吡格雷（降级）在整个研究期间增加，但仍然不常见（12.6%）。基线出血风险在初始P2 Y12抑制剂选择中发挥作用，但与转换的相关性有限，而出血表现与降级显著相关。该研究的结果表明，替格瑞洛已成为最常用的P2 Y12抑制剂，维持期间氯吡格雷的减量增加，基线时的高出血风险可以指导初始治疗选择，这凸显了先发制人的以患者为中心的P2 Y12抑制剂处方的必要性，以优化抗血小板活性并最大限度地降低出血风险。这项队列研究使用国家索赔数据描述了接受经皮冠状动脉介入治疗急性冠状动脉综合征患者中血小板ADP P2 Y12受体抑制剂的选择和转换。血小板ADP P2 Y12受体（P2 Y12）抑制剂加阿司匹林是急性冠状动脉综合征（ACS）经皮冠状动脉介入治疗（PCI）患者的标准治疗。与氯吡格雷相比，普拉格雷和替格瑞洛具有上级抗动脉粥样硬化血栓形成作用，但出血风险增加;随着最近指南的更新，描述当前治疗模式和出血风险在治疗选择中的作用非常重要。描述初始P2 Y12抑制剂选择和转换的长期趋势和决定因素，包括降级（从普拉格雷或替格瑞洛转换为氯吡格雷）。这项回顾性队列研究使用了2010年至2019年的MarketScan商业索赔数据，这些数据针对18岁或以上的患者，这些患者接受了PCI治疗ACS，在过去一年中未使用P2 Y12抑制剂，并在PCI住院出院后30天内填写了P2 Y12抑制剂处方。数据分析时间为2022年2月至5月。氯吡格雷、普拉格雷和替格瑞洛，决定因素包括使用高出血风险学术研究联盟标准测量的出血风险、社会人口统计学特征、P2 Y12抑制剂共付费用和随访期间的出血事件。评估了开始使用药物的患者中每种P2 Y12抑制剂的患病率以及PCI后12个月内转换的患病率。使用多变量logistic和考克斯比例风险回归模型计算基线出血风险与随访和初始治疗期间出血表现和降级之间的相关性。在2010年至2019年期间，确定了62423例开始使用P2 Y12抑制剂的患者（女性，22.4%;男性，77.6%;平均[SD]年龄，54.32 [7.13]岁）。氯吡格雷作为初始治疗的流行率从2010年的77.5%下降到2019年的29.6%，而普拉格雷或替格瑞洛的初始使用率从22.5%上升到60.4%。PCI术后1年内，11.0%的患者转换治疗，主要是为了降级。降级流行率从2010年的1.8%增加到2018年的12.6%。在2016年至2018年期间，22886例患者中有8588例（37.5%）存在严重基线出血风险，这减少了普拉格雷或替格瑞洛作为初始治疗的选择（校正比值比，0.78; 95%CI，0.74-0.84）。在11285例接受普拉格雷或替格瑞洛治疗的患者中，基线时的大出血风险（校正风险比，1.11; 95%CI，1.00-1.23）和随访期间的出血发生率（校正风险比，4.42; 95%CI，3.62-5.93）与降级相关。观察到ACS患者PCI后首选普拉格雷和替格瑞洛作为初始治疗的强烈变化。在研究期间，降级增加。基线大出血风险与初始治疗选择中度相关，但与降级相关性有限。更强效的P2 Y12抑制剂的使用越来越多，强调了加强以患者为中心的先发制人治疗策略的机会，以维持最佳的抗血小板活性，同时降低ACS PCI后亚急性期的出血风险。
What are the treatment dynamics of platelet ADP P2Y12 receptor (P2Y12) inhibitors and factors influencing initial choice and switching following acute coronary syndrome and percutaneous coronary intervention? In this cohort study of 62 423 patients between 2010 and 2019, switching from ticagrelor, which was the primary initial P2Y12 inhibitor prescribed in 2019, or prasugrel to clopidogrel (deescalation) increased across the study period, but remained infrequent (12.6%). Baseline bleeding risk played a role in initial P2Y12 inhibitor selection but had a limited association with switching, while manifestation of bleeding was significantly associated with deescalation. The study’s findings suggest that ticagrelor has emerged as the most commonly prescribed P2Y12 inhibitor, there has been an increase in deescalation to clopidogrel during maintenance, and high bleeding risk at baseline can guide initial treatment selection, highlighting the need for preemptive patient-centered P2Y12 inhibitor prescribing to optimize antiplatelet activity and minimize bleeding risk. This cohort study uses national claims data to describe platelet ADP P2Y12 receptor inhibitor choice and switching among patients who underwent percutaneous coronary intervention for acute coronary syndrome. A platelet ADP P2Y12 receptor (P2Y12) inhibitor plus aspirin is standard therapy for patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Compared with clopidogrel, prasugrel and ticagrelor are associated with superior antiatherothrombotic effects but increased bleeding risk; with recent guideline updates, it is important to describe current treatment patterns and the role of bleeding risk in treatment choice. To describe secular trends and determinants of initial P2Y12 inhibitor choice and switching, including deescalation (switch from prasugrel or ticagrelor to clopidogrel). This retrospective cohort study used MarketScan Commercial Claims Data from 2010 to 2019 for patients aged 18 years or older who underwent PCI for ACS, had no P2Y12 inhibitor use in the past year, and filled a P2Y12 inhibitor prescription within 30 days after PCI hospitalization discharge. Data were analyzed from February to May 2022. Clopidogrel, prasugrel, and ticagrelor, with determinants including bleeding risk measured using Academic Research Consortium for High Bleeding Risk criteria, sociodemographic characteristics, P2Y12 inhibitor copays, and bleeding events during follow-up. The prevalence of each P2Y12 inhibitor among patients who initiated the drugs and the prevalence of switching within 12 months after PCI were evaluated. The association between baseline bleeding risk and bleeding manifestations during follow-up and initial treatment and deescalation were calculated using multivariable logistic and Cox proportional hazards regression models. Between 2010 and 2019, 62 423 patients were identified who initiated P2Y12 inhibitors (females, 22.4%; males, 77.6%; mean [SD] age, 54.32 [7.13] years). The prevalence of clopidogrel as initial therapy decreased from 77.5% in 2010 to 29.6% in 2019, while initial use of prasugrel or ticagrelor increased from 22.5% to 60.4%. Within 1 year after PCI, 11.0% of patients switched therapy, mostly for deescalation. Deescalation prevalence increased from 1.8% in 2010 to 12.6% in 2018. Between 2016 and 2018, 8588 of 22 886 (37.5%) patients had major baseline bleeding risk, which decreased the selection of prasugrel or ticagrelor as initial therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.84). Among 11 285 patients who initiated prasugrel or ticagrelor, major bleeding risk at baseline (adjusted hazard ratio, 1.11; 95% CI, 1.00-1.23) and the occurrence of bleeding during follow-up (adjusted hazard ratio, 4.42; 95% CI, 3.62-5.93) were associated with deescalation. A strong shift in preference for prasugrel and ticagrelor as initial therapy following PCI for ACS was observed. Deescalation increased over the study period. Major bleeding risk at baseline was moderately associated with initial treatment choice but had a limited association with deescalation. The increasing use of more potent P2Y12 inhibitors emphasizes opportunities to enhance preemptive patient-centered treatment strategies to maintain optimal antiplatelet activity while reducing bleeding risk during the subacute period following PCI for ACS.
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影响因子：
2.1
作者：
Kim, Kibum;Lee, Todd A.;Walton, Surrey M.
通讯作者：
Walton, Surrey M.
影响因子：
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作者：
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影响因子：
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作者：
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通讯作者：
Bolognese, Leonardo
影响因子：
24
作者：
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通讯作者：
Wang, Tracy Y.
影响因子：
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作者：
Kim, K. A.;Park, P. W.;Park, J-Y
通讯作者：
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