title: Clinical outcomes, health resource use, and cost in patients with early versus late dual or triple anti-platelet treatment for acute coronary syndrome.
abstract: BACKGROUND
  Acute coronary syndrome (ACS) guidelines recommend early dual anti-platelet therapy (thienopyridines + acetylsalicylic acid [aspirin]). However, triple therapy (thienopyridines + aspirin + glycoprotein IIb/IIIa receptor inhibitors [GRIs]) has shown benefit in clinical trials.
  
  
  OBJECTIVE
  This study assessed real-world ACS treatment patterns and outcomes in the acute care setting.
  
  
  METHODS
  A retrospective analysis of patients admitted to hospital with ACS (index event) from January 2007 to December 2009 was conducted (Thomson's MarketScan Hospital Drug Database).
  
  
  METHODS
  Eligible patients were ≥18 years of age, of either sex, and had primary admission and discharge diagnoses of ACS.
  
  
  METHODS
  Cohorts were defined by anti-platelet treatment and then by the timing of treatment initiation (early initiation: within ≤2 days of admission; late initiation: ≥2 days post-admission). Patient characteristics, clinical outcomes, resource utilization, and costs were assessed using descriptive statistics.
  
  
  RESULTS
  A total of 249,907 eligible patients were placed into four treatment cohorts (aspirin assumed for all patients): aspirin only; clopidogrel only (dual therapy); GRI only (dual therapy); and clopidogrel + GRI (triple therapy). Patients in the 'clopidogrel-only' cohort were more likely to be older, female, and have more co-morbidities than those in other cohorts; stroke (6.2 %) and re-hospitalization (15.4 %) rates were higher than in the 'GRI-only' and 'triple therapy' cohorts. The GRI-only cohort had higher major bleeding rates (3.3 %), mortality (7.6 %), and costs ($US21,975 [year 2010 values]) than the clopidogrel-only and triple-therapy cohorts. Late initiation cohorts were more likely to be older, female, and have more co-morbidities than early initiation cohorts. Major bleeding was more likely with GRI-only patients (regardless of initiation timing) than with other cohorts. Late-treated clopidogrel-only patients had higher rates of stroke (6.9 %), ACS-related re-admissions (6.1 %), and all-cause re-admissions (15.9 %) than other cohorts. Late treatment was associated with longer length of stay and significantly higher costs.
  
  
  CONCLUSIONS
  Real-world anti-platelet treatment patterns are consistent with ACS guidelines recommending early initiation and selective GRI use. In contrast to recommendations, some outcomes were improved with triple therapy compared with dual therapy.
authors.affiliation: DataMed Solutions LLC, 4660 Stonehill Street, Hilliard, OH 43026, USA.
authors.forename: Howard
authors.initials: H
authors.lastname: Friedman
authors.forename: Patrick
authors.initials: P
authors.lastname: Mollon
authors.forename: Jean
authors.initials: J
authors.lastname: Lian
authors.forename: Prakash
authors.initials: P
authors.lastname: Navaratnam
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000191:economics*; D000368:Aged; D001792:Blood Platelets / Q000187:drug effects; D004359:Drug Therapy, Combination / Q000191:economics / Q000379:methods; D005260:Female; D006295:Health Resources / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000191:economics* / Q000627:therapeutic use*; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors