Switching between thienopyridines in patients with acute myocardial infarction and quality of care

Abstract

Objective: In acute coronary syndromes, switching between thienopyridines is frequent. The aims of the study were to assess the association between switching practices and quality of care.

Methods: Registry study performed in 213 French public university, public non-academic and private hospitals. All consecutive patients admitted for acute myocardial infarction (MI; <48 hours) between 1/10/2010 and 30/11/2010 were eligible. Clinical and biological data were recorded up to 12 months follow-up.

Results: Among 4101 patients receiving thienopyridines, a switch was performed in 868 (21.2%): 678 (16.5%) from clopidogrel to prasugrel and 190 (4.6%) from prasugrel to clopidogrel. Predictors of switch were ST segment elevation MI presentation, admission to a cardiology unit, previous percutaneous coronary intervention, younger age, body weight >60 kg, no history of stroke, cardiac arrest, anaemia or renal dysfunction. In patients with a switch, eligibility for prasugrel was >82% and appropriate use of a switch was 86% from clopidogrel to prasugrel and 20% from prasugrel to clopidogrel. Quality indicators scored higher in the group with a switch and also in centres where the switch rate was higher.

Conclusions: As applied in the French Registry on Acute ST-elevation and non ST-elevation Myocardial Infarction (FAST-MI) registry, switching from one P2Y12 inhibitor to another led to a more appropriate prescription and was associated with higher scores on indicators of quality of care.

Figure 1

Flow chart of the study population according to thienopyridines used in the FAST-MI registry in patients with STEMI and NSTEMI. FAST-MI, French Registry on Acute ST-elevation and non ST-elevation Myocardial Infarction; MI, myocardial infarction; NSTEMI, non-ST segment elevation myocardial infarction; STEMI, ST segment elevation myocardial infarction.

Figure 2

Proportion of patients receiving oral antiplatelet agents at each time point (pretreatment, prehospital, admission to 24 hours, 24–48 hours and at discharge).

Figure 3

Forest plot of ORs for the predictors of switch in thienopyridines. STEMI, ST segment elevation myocardial infarction; ED, emergency department; PCI, percutaneous coronary intervention.

Figure 4

Rates of quality indicators across categories of centres (according to the rate of switch). DAPT, dual antiplatelet therapy; betab: β-blockers, ACEI, ACE inhibitors; dis, discharge; composite, composite indicator calculated using opportunity scoring (one point by applicable indicator divided by the number of applicable indicators); composite_st, composite indicator for patients with ST elevation myocardial infarction (including reperfusion within 120 min by primary percutaneous coronary intervention or within 60 min by thrombolysis).