Real-life management of dual antiplatelet therapy interruption: the REGINA survey.
BACKGROUND
Concern about procedure-related bleeding is a major reason for premature discontinuation of dual oral antiplatelet therapy (APT); treatment cessation is detrimental in patients with coronary artery disease (CAD), especially after drug-eluting stent (DES) placement. The nationwide REGINA survey was designed to evaluate how the interruption of dual APT is managed in the 'real world'.


METHODS
Physicians (2700/4581) were randomly selected to participate in a computer-assisted telephone interview. Knowledge about DES and APT was appraised by multiple-choice questions. Strategies for temporary interruption of dual APT before an invasive or surgical procedure were evaluated using 21 scenarios, including high-risk (30 days after DES) and low-risk (18 months after DES) periods.


RESULTS
Out of 2700 practitioners, 2515 completed the interview. Rates of correct answers to basic knowledge questions ranged from 0% (dentists) to 52% (cardiologists). Unjustified total interruption of dual APT was much more frequent than expected (22.0% vs. 11.8%). A strategy of total interruption was less frequently chosen in the period of high ischemic risk compared to the low-risk period (13.7% vs. 31.1%, p<0.0001). Dual APT interruption in patients who require additional invasive cardiac or surgical procedures depended on type of physician consulted (more frequent in specialists than general practitioners or dentists), and on the physician's age and practice type (rural/private vs. urban/hospital). Correct answers were more frequently given in situations bearing a major risk, either ischemic or bleeding risk, than in those with no risk (49.2% vs. 30.2%, p<0.0001). Low-molecular-weight heparin was the substitution therapy in over two-thirds of scenarios and was associated with longer periods of APT interruption.


CONCLUSIONS
Adequate management of APT in patients with intracoronary stents who undergo potentially haemorrhagic invasive procedures depends mainly on the type of physician involved and their practice rather than on a carefully weighted assessment of ischemic/bleeding risk. Our findings suggest a lack of scientific evidence, insufficient knowledge of guidelines, and poor communication between physicians managing these patients.
Collet
Jean-Philippe
JP
Bureau 236, Inserm 937, institut de cardiologie, hôpital Pitié-Salpêtrière (AP-HP), 47, boulevard de l'Hôpital, 75013 Paris, France.
Aout
Mounir
M
Alantar
Alp
A
Coriat
Pierre
P
Napoléon
Bertrand
B
Thomas
Daniel
D
Trosini-Desert
Valéry
V
Tucas
Gilbert
G
Vicaut
Eric
E
Montalescot
Gilles
G
D000284:Administration, Oral; D000328:Adult; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation*; D001291:Attitude of Health Personnel; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D019983:Guideline Adherence; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D019106:Postoperative Hemorrhage / Q000139:chemically induced / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013514:Surgical Procedures, Operative; D011795:Surveys and Questionnaires; D013927:Thrombosis / Q000209:etiology / Q000517:prevention & control*
D010975:Platelet Aggregation Inhibitors