title: Delay in filling first clopidogrel prescription after coronary stenting is associated with an increased risk of death and myocardial infarction.
abstract: BACKGROUND
  Patients frequently experience difficulties with medication compliance after hospital discharge. We investigated the effect of a delay in filling a first clopidogrel prescription after hospital discharge on clinical outcomes subsequent to coronary stenting.
  
  
  RESULTS
  Hospital administrative, community pharmacy, and cardiac revascularization data were determined for all patients receiving a coronary stent in British Columbia 2004-2006 with follow-up out to 2 years. Cox's proportional hazard regression analysis, adjusting for baseline demographics and procedural variables, was performed to examine the effects of delay in filling a clopidogrel prescription after hospital discharge on clinical outcomes.Of 15 629 patients treated with coronary stents, 3599 received at least 1 drug-eluting stent (DES), whereas 12 030 received bare metal stents (BMS) alone. In total, 1064 (30%) and 3758 (31%) patients in the DES and BMS groups, respectively, failed to fill a prescription within 3 days of discharge (median, 1 day; interquartile range [IQR], 1 to 3). After regression analysis, a delay of >3 days was predictive of mortality and recurrent myocardial infarction (MI) irrespective of stent type (DES: hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.7 to 3.4; and HR, 2.0; 95% CI, 1.5 to 2.7, respectively, and BMS: HR, 2.2; 95% CI, 1.9 to 2.6; and HR, 1.8; 95% CI, 1.5 to 2.1, respectively). This excess hazard was greatest in the 30-day period immediately after hospital discharge (mortality: HR, 5.5; 95% CI, 3.5 to 8.6; and MI: HR, 3.1; 95% CI, 2.4 to 4.0, for all patients).
  
  
  CONCLUSIONS
  Delays in patients filling their first prescription for clopidogrel after coronary stenting are common and associated with adverse clinical outcomes, irrespective of stent type. Strategies to reduce delays have the potential to improve clinical outcomes.
authors.affiliation: Royal Infirmary of Edinburgh, Edinburgh, UK (N.L.C.) University of Edinburgh, Edinburgh, UK (N.L.C.).
authors.forename: Nicholas L
authors.initials: NL
authors.lastname: Cruden
authors.affiliation: Royal Bournemouth Hospital, Bournemouth, UK (J.N.D.).
authors.forename: Jehangir N
authors.initials: JN
authors.lastname: Din
authors.affiliation: Victoria Heart Institute Foundation, Victoria, British Columbia, Canada (C.J., R.S., D.H., P.K., S.D.R., A.D.S.).
authors.forename: Christian
authors.initials: C
authors.lastname: Janssen
authors.affiliation: Victoria Heart Institute Foundation, Victoria, British Columbia, Canada (C.J., R.S., D.H., P.K., S.D.R., A.D.S.).
authors.forename: Reginald
authors.initials: R
authors.lastname: Smith
authors.affiliation: Victoria Heart Institute Foundation, Victoria, British Columbia, Canada (C.J., R.S., D.H., P.K., S.D.R., A.D.S.).
authors.forename: J David
authors.initials: JD
authors.lastname: Hilton
authors.affiliation: Victoria Heart Institute Foundation, Victoria, British Columbia, Canada (C.J., R.S., D.H., P.K., S.D.R., A.D.S.).
authors.forename: W Peter
authors.initials: WP
authors.lastname: Klinke
authors.affiliation: Providence Health Care, Vancouver, British Columbia, Canada (R.G.C.).
authors.forename: Ron G
authors.initials: RG
authors.lastname: Carere
authors.affiliation: Victoria Heart Institute Foundation, Victoria, British Columbia, Canada (C.J., R.S., D.H., P.K., S.D.R., A.D.S.).
authors.forename: Simon D
authors.initials: SD
authors.lastname: Robinson
authors.affiliation: Victoria Heart Institute Foundation, Victoria, British Columbia, Canada (C.J., R.S., D.H., P.K., S.D.R., A.D.S.).
authors.forename: Anthony Della
authors.initials: AD
authors.lastname: Siega
mesh_terms: D000368:Aged; D000077144:Clopidogrel; D054855:Drug-Eluting Stents / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000209:etiology; D062645:Percutaneous Coronary Intervention / Q000379:methods / Q000401:mortality* / Q000706:statistics & numerical data; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D016016:Proportional Hazards Models; D012307:Risk Factors; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome; D016903:Drug Monitoring
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine
keywords: clopidogrel; death; myocardial infarction; percutaneous coronary intervention