title: In-hospital switching between clopidogrel and prasugrel among patients with acute myocardial infarction treated with percutaneous coronary intervention: insights into contemporary practice from the national cardiovascular data registry.
abstract: BACKGROUND
  Although randomized clinical trials have compared clopidogrel with higher potency ADP receptor inhibitors (ADPris) among patients with myocardial infarction, little is known about the frequency and factors associated with switching between ADPris in clinical practice.
  
  
  RESULTS
  We studied 47 040 patients with myocardial infarction treated with percutaneous coronary intervention, who received either clopidogrel or prasugrel within 24 hours of admission at 361 US hospitals from July 2009 to June 2011 using the merged Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines and CathPCI Registry database. Hierarchical logistic regression modeling was used to determine factors independently associated with in-hospital ADPri switching. Among 40 531 patients treated initially in-hospital with clopidogrel, 2125 (5.2%) were discharged on prasugrel; this frequency steadily increased from 0% to 7% during the study period. Among 6509 patients treated initially in-hospital with prasugrel, 751 (11.5%) were discharged on clopidogrel. The frequency of this switch increased from 6% to 18% during the first 2 quarters of the study period and decreased to 9% by the end. Switching clopidogrel to prasugrel was associated with high-risk angiographic characteristics (thrombotic, long, and bifurcating lesions), reinfarction in-hospital, and private health insurance coverage. Older age, previous cerebrovascular event, in-hospital coronary artery bypass grafting, in-hospital bleeding, and warfarin use at discharge were associated with switching prasugrel to clopidogrel.
  
  
  CONCLUSIONS
  Clopidogrel and prasugrel are not uncommonly switched in-hospital in patients with myocardial infarction undergoing percutaneous coronary intervention. In contemporary US practice, in addition to risk for bleeding and recurrent ischemic events, medical drug coverage is a major determinant of ADPri selection.
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.). bagaia@smh.ca.
authors.forename: Akshay
authors.initials: A
authors.lastname: Bagai
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Yongfei
authors.initials: Y
authors.lastname: Wang
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Jeptha P
authors.initials: JP
authors.lastname: Curtis
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Hitinder S
authors.initials: HS
authors.lastname: Gurm
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Binita
authors.initials: B
authors.lastname: Shah
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Asim N
authors.initials: AN
authors.lastname: Cheema
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Jorge F
authors.initials: JF
authors.lastname: Saucedo
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Granger
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Robert L
authors.initials: RL
authors.lastname: McNamara
authors.affiliation: From the Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B., A.N.C.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C., R.L.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., E.D.P., C.B.G., M.T.R., K.P.A.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (H.S.G.); New York University School of Medicine (B.S.); NorthShore University Health System, Evanston, IL (J.F.S.); and Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).
authors.forename: Karen P
authors.initials: KP
authors.lastname: Alexander
mesh_terms: D000208:Acute Disease; D000367:Age Factors; D000368:Aged; D000077144:Clopidogrel; D057915:Drug Substitution / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000601:surgery; D062645:Percutaneous Coronary Intervention; D010879:Piperazines / Q000008:administration & dosage / Q000009:adverse effects; D011183:Postoperative Complications / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D000068799:Prasugrel Hydrochloride; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage / Q000009:adverse effects; D012008:Recurrence; D012042:Registries; D012307:Risk Factors; D013876:Thiophenes / Q000008:administration & dosage / Q000009:adverse effects; D013927:Thrombosis / Q000209:etiology / Q000517:prevention & control*; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives; D014481:United States
chemical_list: D010879:Piperazines; D058921:Purinergic P2Y Receptor Antagonists; D013876:Thiophenes; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine
keywords: acute coronary syndrome; adenosine receptor antagonists; antiplatelet drugs