Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: results from the PREMIER registry.
BACKGROUND
Although drug-eluting stents (DES) significantly reduce restenosis, they require 3 to 6 months of thienopyridine therapy to prevent stent thrombosis. The rate and consequences of prematurely discontinuing thienopyridine therapy after DES placement for acute myocardial infarction (MI) are unknown.


RESULTS
We used prospectively collected data from a 19-center study of MI patients to examine the prevalence and predictors of thienopyridine discontinuation 30 days after DES treatment. We then compared the mortality and cardiac hospitalization rates for the next 11 months between those who stopped and those who continued thienopyridine therapy. Among 500 DES-treated MI patients who were discharged on thienopyridine therapy, 68 (13.6%) stopped therapy within 30 days. Those who stopped were older, less likely to have completed high school or be married, more likely to avoid health care because of cost, and more likely to have had preexisting cardiovascular disease or anemia at presentation. They were also less likely to have received discharge instructions about their medications or a cardiac rehabilitation referral. Patients who stopped thienopyridine therapy by 30 days were more likely to die during the next 11 months (7.5% versus 0.7%, P<0.0001; adjusted hazard ratio=9.0; 95% confidence interval=1.3 to 60.6) and to be rehospitalized (23% versus 14%, P=0.08; adjusted hazard ratio=1.5; 95% confidence interval=0.78 to 3.0).


CONCLUSIONS
Almost 1 in 7 MI patients who received a DES were no longer taking thienopyridines by 30 days. Prematurely stopping thienopyridine therapy was strongly associated with subsequent mortality. Strategies to improve the use of thienopyridines are needed to optimize the outcomes of MI patients treated with DES.
Spertus
John A
JA
MPH, Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO 64111. spertusj@umkc.edu.
Kettelkamp
Richard
R
Vance
Clifton
C
Decker
Carole
C
Jones
Philip G
PG
Rumsfeld
John S
JS
Messenger
John C
JC
Khanal
Sanjaya
S
Peterson
Eric D
ED
Bach
Richard G
RG
Krumholz
Harlan M
HM
Cohen
David J
DJ
D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D002317:Cardiovascular Agents / Q000627:therapeutic use; D002423:Cause of Death; D000077144:Clopidogrel; D003131:Combined Modality Therapy; D023903:Coronary Restenosis / Q000401:mortality / Q000517:prevention & control*; D004334:Drug Administration Schedule; D004343:Drug Implants; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015993:Life Tables; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009203:Myocardial Infarction / Q000188:drug therapy / Q000628:therapy*; D010353:Patient Education as Topic; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D015995:Prevalence; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011725:Pyridines / Q000008:administration & dosage / Q000627:therapeutic use*; D012042:Registries; D020123:Sirolimus / Q000008:administration & dosage / Q000627:therapeutic use*; D015607:Stents; D016019:Survival Analysis; D013927:Thrombosis / Q000517:prevention & control*; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000627:therapeutic use; D016896:Treatment Outcome; D016312:Treatment Refusal
D002317:Cardiovascular Agents; D004343:Drug Implants; D010975:Platelet Aggregation Inhibitors; D011725:Pyridines; C446540:thienopyridine; D000077144:Clopidogrel; D013988:Ticlopidine; D020123:Sirolimus