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Coronary artery disease
Original research article
Dual antiplatelet therapy in non-ST elevation acute coronary syndromes at Veterans Affairs Hospitals
  1. Javier Alfonso Valle1,2,
  2. Kevin Josey1,
  3. Andrew F Prouse2,3,
  4. Jeffrey Zimmet4,
  5. Stephen W Waldo1
  1. 1 Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
  2. 2 Department of Medicine, Division of Cardiology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
  3. 3 Department of Medicine, Division of Cardiology, Denver Health Medical Center, Denver, Colorado, USA
  4. 4 Department of Medicine Division of Cardiology, San Francisco VA Medical Center, San Francisco, California, USA
  1. Correspondence to Dr Javier Alfonso Valle, Division of Cardiology, University of Colorado, Aurora 80045, USA; javier.valle{at}Ucdenver.edu

Abstract

Objective Current guidelines recommend that patients with non-ST elevation acute coronary syndromes (NSTEACS) receive dual antiplatelet therapy (DAPT) early in hospitalisations. However, observational studies suggest that this rarely occurs. We evaluated site-specific variation and clinical outcomes associated with early DAPT among patients undergoing angiography for NSTEACS.

Methods In this observational analysis, we identified patients undergoing angiography for NSTEACS in Veterans Affairs hospitals from 2008 to 2016 and assessed characteristics and site variation associated with early DAPT (administration <24 hours of admission). Using propensity matching, we compared time to revascularisation, recurrent myocardial infarction (MI) and mortality between those receiving early DAPT and those not receiving early DAPT (administration ≥24 hours).

Results Of 45 569 patients undergoing angiography for NSTEACS, 15 084 (33%) received early DAPT. Early DAPT was more frequent in patients with non-ST elevation MI, prior surgical revascularisation and among patients undergoing revascularisation. There was a greater than twofold difference in early DAPT across sites, independent of patient characteristics (median OR 2.43, 95% CI 2.28 to 2.55). There was no difference in time topercutaneous coronary intervention (PCI) between groups, but a significant delay to surgical revascularisation with early DAPT (median 4 vs 3 days, p<0.001) without reduction in hazard of death or MI (HR 1.08, 95% CI 1.00 to 1.16) and similar results demonstrated in the subgroup of patients undergoing revascularisation (HR 1.02, 95% CI 0.91 to 1.13).

Conclusion Among NSTEACS patients undergoing coronary angiography, early DAPT was not associated with improvement of outcomes but was associated with delays in surgical revascularisation.

  • percutaneous coronary intervention
  • acute coronary syndromes
  • health care delivery
  • coronary artery disease surgery

https://doi.org/10.1136/heartjnl-2018-314553

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    Footnotes

    • Contributors Each of the authors listed on this manuscript provided substantial contribution to the conception, design, analysis and/or interpretation of the data, as well as participating in the drafting and revision of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Disclaimer The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

    • Competing interests SWW received research support to the Denver Research Institute from Abiomed, Cardiovascular Systems Incorporated and Merck Pharmaceuticals. The other authors have no industry relations to disclose.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Data are obtained from the Veterans Affairs Clinical Assessment, Reporting and Tracking program (CART), a national quality and safety program for invasive cardiac procedures performed throughout the VA, and the electronic medical record of the Veterans Affairs Healthcare System. These data are not publicly available and are limited to groups operating on behalf of the Department of Veterans Affairs.

    • Patient consent for publication Not required.