title: Prasugrel Use Following PCI and Associated Patient Outcomes: Insights From the National VA CART Program.
abstract: BACKGROUND
  Prasugrel is more effective than clopidogrel in preventing thrombotic complications after percutaneous coronary intervention (PCI) among patients with acute coronary syndromes (ACS), but it increases the risk of bleeding in subgroups of patients. There is limited data on whether prasugrel use in routine practice is targeted to clinical settings with greatest anticipated patient benefit.
  
  
  METHODS
  In a national cohort of 11 617 veterans who underwent PCI between 2010 and 2013 at Veterans Administration hospitals nationwide, we assessed overall trends in the use of prasugrel and the frequency of prasugrel use in patients with contraindications (prior transient ischemic attack or cerebrovascular accident), higher bleeding risk (age ≥75 or weight <60 kg), and nonindicated settings (non-acute coronary syndrome [non-ACS]). We then evaluated the association between prasugrel use and 1-year risk-adjusted mortality, myocardial infarction, and major bleeding rates.
  
  
  RESULTS
  Overall, 1040 (9.0%) patients who received prasugrel after PCI were included. Prasugrel was infrequently used in contraindicated (2.4%) or higher-bleeding-risk (1.8%) settings. Additionally, 35.8% of patients received prasugrel in settings that lack evidence of clinical benefit (ie, non-ACS). Compared with clopidogrel, there were no significant differences in risk-adjusted mortality, myocardial infarction, or major bleeding outcomes with prasugrel therapy at 1-year follow-up.
  
  
  CONCLUSIONS
  Prasugrel use after PCI in the Veterans Administration is low and prasugrel was rarely used in contraindicated or high-bleeding-risk settings. However, a third of patients received prasugrel for off-label non-ACS indications that lack efficacy data.
authors: Division of Cardiology, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania.
authors: Vikas
authors: V
authors: Aggarwal
authors: Department of Cardiology, University of Colorado Denver School of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado.|Department of Cardiology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado.
authors: Ehrin J
authors: EJ
authors: Armstrong
authors: Department of Cardiology, University of Colorado Denver School of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado.|Department of Cardiology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado.
authors: Wenhui
authors: W
authors: Liu
authors: Department of Cardiology, University of Colorado Denver School of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado.|Department of Cardiology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado.
authors: Thomas M
authors: TM
authors: Maddox
authors: Department of Cardiology, University of Colorado Denver School of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado.|Department of Cardiology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado.
authors: P Michael
authors: PM
authors: Ho
authors: Department of Cardiology, University of Colorado Denver School of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado.|Department of Cardiology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado.|Department of Cardiology, Colorado School of Public Health, Aurora, Colorado.
authors: Evan
authors: E
authors: Carey
authors: Department of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
authors: Tracy
authors: T
authors: Wang
authors: Department of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
authors: Matthew
authors: M
authors: Sherwood
authors: Department of Cardiology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado.|Department of Cardiology, Institute for Health Research, Kaiser Permanente, Denver, Colorado.
authors: Thomas T
authors: TT
authors: Tsai
authors: Department of Cardiology, University of Colorado Denver School of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado.|Department of Cardiology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado.
authors: John S
authors: JS
authors: Rumsfeld
authors: Department of Cardiology, University of Colorado Denver School of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado. steven.bradley@va.gov.|Department of Cardiology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado. steven.bradley@va.gov.
authors: Steven M
authors: SM
authors: Bradley
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003328:Coronary Thrombosis / Q000209:etiology / Q000517:prevention & control; D016208:Databases, Factual; D017723:Drug Utilization Review; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control; D056687:Off-Label Use; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D010818:Practice Patterns, Physicians' / Q000639:trends*; D000068799:Prasugrel Hydrochloride / Q000009:adverse effects / Q000627:therapeutic use*; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans
chemical_list: D010975:Platelet Aggregation Inhibitors; D000068799:Prasugrel Hydrochloride