title: Early clopidogrel versus prasugrel use among contemporary STEMI and NSTEMI patients in the US: insights from the National Cardiovascular Data Registry.
abstract: BACKGROUND
  P2Y12 antagonist therapy improves outcomes in acute myocardial infarction (MI) patients. Novel agents in this class are now available in the US. We studied the introduction of prasugrel into contemporary MI practice to understand the appropriateness of its use and assess for changes in antiplatelet management practices.
  
  
  RESULTS
  Using ACTION Registry-GWTG (Get-with-the-Guidelines), we evaluated patterns of P2Y12 antagonist use within 24 hours of admission in 100 228 ST elevation myocardial infarction (STEMI) and 158 492 Non-ST elevation myocardial infarction (NSTEMI) patients at 548 hospitals between October 2009 and September 2012. Rates of early P2Y12 antagonist use were approximately 90% among STEMI and 57% among NSTEMI patients. From 2009 to 2012, prasugrel use increased significantly from 3% to 18% (5% to 30% in STEMI; 2% to 10% in NSTEMI; P for trend <0.001 for all). During the same period, we observed a decrease in use of early but not discharge P2Y12 antagonist among NSTEMI patients. Although contraindicated, 3.0% of patients with prior stroke received prasugrel. Prasugrel was used in 1.9% of patients ≥75 years and 4.5% of patients with weight <60 kg. In both STEMI and NSTEMI, prasugrel was most frequently used in patients at the lowest predicted risk for bleeding and mortality. Despite lack of supporting evidence, prasugrel was initiated before cardiac catheterization in 18% of NSTEMI patients.
  
  
  CONCLUSIONS
  With prasugrel as an antiplatelet treatment option, contemporary practice shows low uptake of prasugrel and delays in P2Y12 antagonist initiation among NSTEMI patients. We also note concerning evidence of inappropriate use of prasugrel, and inadequate targeting of this more potent therapy to maximize the benefit/risk ratio.
authors.affiliation: Division of Cardiovascular Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC.
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Sherwood
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Wiviott
authors.forename: S Andrew
authors.initials: SA
authors.lastname: Peng
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.forename: James
authors.initials: J
authors.lastname: Delemos
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
mesh_terms: D000368:Aged; D000077144:Clopidogrel; D004334:Drug Administration Schedule; D017723:Drug Utilization Review; D005260:Female; D019983:Guideline Adherence / Q000639:trends; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D010879:Piperazines / Q000008:administration & dosage* / Q000009:adverse effects; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000639:trends*; D000068799:Prasugrel Hydrochloride; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage* / Q000009:adverse effects; D012042:Registries; D012189:Retrospective Studies; D013876:Thiophenes / Q000008:administration & dosage* / Q000009:adverse effects; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D010879:Piperazines; D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D013876:Thiophenes; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine
keywords: P2Y12 antagonist; myocardial infarction; prasugrel
references.citation: Circulation. 2012 Aug 14;126(7):875-910
references.pmid: 22800849
references.citation: Am J Cardiol. 2006 May 15;97(10):1478-81
references.pmid: 16679087
references.citation: N Engl J Med. 2012 Oct 4;367(14):1297-309
references.pmid: 22920930
references.citation: Arch Intern Med. 2006 Apr 10;166(7):806-11
references.pmid: 16606819
references.citation: Am Heart J. 2011 Jan;161(1):113-122.e2
references.pmid: 21167342
references.citation: Circulation. 2013 Jan 29;127(4):529-55
references.pmid: 23247303
references.citation: N Engl J Med. 2007 Nov 15;357(20):2001-15
references.pmid: 17982182
references.citation: Am Heart J. 2006 Jun;151(6):1205-13
references.pmid: 16781220
references.citation: Am Heart J. 2007 Feb;153(2):289-95
references.pmid: 17239691
references.citation: JAMA. 2004 Jun 9;291(22):2727-33
references.pmid: 15187054
references.citation: Heart. 2010 Nov;96(22):1798-802
references.pmid: 20736202
references.citation: N Engl J Med. 2001 Aug 16;345(7):494-502
references.pmid: 11519503
references.citation: Lancet. 2009 Feb 28;373(9665):723-31
references.pmid: 19249633
references.citation: JAMA. 2009 Dec 9;302(22):2458-64
references.pmid: 19996401
references.citation: N Engl J Med. 2013 Sep 12;369(11):999-1010
references.pmid: 23991622
references.citation: Arch Intern Med. 2006 Oct 9;166(18):2027-34
references.pmid: 17030838
references.citation: Am Heart J. 2009 Apr;157(4):642-50.e1
references.pmid: 19332190
references.citation: J Clin Pharm Ther. 2008 Aug;33(4):339-48
references.pmid: 18613851
references.citation: J Am Coll Cardiol. 2006 Jul 18;48(2):281-6
references.pmid: 16843176
references.citation: JAMA. 2005 Sep 14;294(10):1224-32
references.pmid: 16143698
references.citation: BMJ. 2000 Mar 18;320(7237):788-91
references.pmid: 10720369
references.citation: N Engl J Med. 2005 Mar 24;352(12):1179-89
references.pmid: 15758000
references.citation: J Am Coll Cardiol. 2009 Dec 1;54(23):2205-41
references.pmid: 19942100
references.citation: Circulation. 2008 Oct 14;118(16):1626-36
references.pmid: 18757948
references.citation: MedGenMed. 2000 Feb 14;2(1):E13
references.pmid: 11104459
references.citation: Mayo Clin Proc. 2012 Oct;87(10):982-90
references.pmid: 22877654
references.citation: Circulation. 2007 Dec 18;116(25):2923-32
references.pmid: 18056526
references.citation: Am J Cardiol. 2011 Apr 15;107(8):1136-43
references.pmid: 21324428
references.citation: Am Heart J. 2008 Sep;156(3):606-12
references.pmid: 18760147
references.citation: Lancet. 2001 Aug 18;358(9281):527-33
references.pmid: 11520521
references.citation: Arch Intern Med. 2007 May 28;167(10):1009-16
references.pmid: 17533203
references.citation: Eur J Cardiovasc Prev Rehabil. 2008 Apr;15(2):173-8
references.pmid: 18391644
references.citation: Lancet. 2005 Nov 5;366(9497):1607-21
references.pmid: 16271642
references.citation: Circulation. 2009 Apr 14;119(14):1873-82
references.pmid: 19332461
references.citation: Am J Emerg Med. 2013 Jul;31(7):1005-11
references.pmid: 23702070