Variation in Practice Regarding Pretreatment With Dual Antiplatelet Therapy for Patients With Non-ST Elevation Myocardial Infarction.
Despite guideline recommendations, a significant number of patients with non-ST elevation myocardial infarction (NSTEMI) do not receive dual antiplatelet therapy (DAPT) before angiography "pretreatment." While there may be valid clinical reasons to not pretreat, such as concern for bleeding or multivessel disease warranting coronary artery bypass graft surgery, the degree of variability and factors associated with DAPT pretreatment are unknown.



From the multicenter TRIUMPH registry, 1632 NSTEMI patients were not taking DAPT on admission and were included in the study cohort. Among the study patients, only 22% patients received DAPT pretreatment. A multivariable logistic regression model showed that race other than white or black (odds ratio [OR] 0.41, 95% CI 0.21-0.83), hemoglobin level (OR 1.18, 95% CI 1.08-1.29), patients' bleeding risk (assessed with NCDR CathPCI Bleeding Risk Score) (OR 0.85, 95% CI 0.74-0.99), and severe left ventricular dysfunction (OR 0.3, 95% CI 0.13-0.65) were the main predictors of pretreatment with DAPT, whereas likelihood of needing coronary artery bypass graft surgery (GRACE prediction model) was not (OR 1.09, 95% CI 0.88-1.35). Median ORs were calculated to assess variability of receiving DAPT pretreatment across sites after adjustment for patient characteristics. Receiving DAPT pretreatment varied substantially across sites (range 0-100%, mean OR 3.94, P<0.0001).



While deviating from guideline-recommended DAPT pretreatment in patients with NSTEMI was associated with patient factors (eg, bleeding risk), marked variation was present across sites after accounting for patient-level characteristics. This suggests that site-level interventions are needed to improve concordance with current guidelines.
Saint Luke's Mid America Heart Institute, Kansas City, MO University of Missouri, Kansas City, MO shafiqa@umkc.edu.
Ali
A
Shafiq
University of Colorado, Aurora, CO.
Javier
J
Valle
Inje University Busan Paik Hospital, Busan, Korea.
Jae-Sik
JS
Jang
Saint Luke's Mid America Heart Institute, Kansas City, MO University of Missouri, Kansas City, MO.
Mohammed
M
Qintar
Saint Luke's Mid America Heart Institute, Kansas City, MO.
Kensey
K
Gosch
Saint Luke's Mid America Heart Institute, Kansas City, MO University of Missouri, Kansas City, MO.
David J
DJ
Cohen
Mayo Clinic, Rochester, MN.
Mandeep
M
Singh
Barnes Jewish Hospital, Washington University, St Louis, MO.
Richard
R
Bach
Saint Luke's Mid America Heart Institute, Kansas City, MO University of Missouri, Kansas City, MO.
John A
JA
Spertus
D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D004359:Drug Therapy, Combination; D005260:Female; D019983:Guideline Adherence; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D000072658:Non-ST Elevated Myocardial Infarction / Q000188:drug therapy*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012042:Registries; D018570:Risk Assessment; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy
D010975:Platelet Aggregation Inhibitors
dual antiplatelet therapy; non–ST‐elevation myocardial infarction; variation in care