Ninety-Day Readmission and Long-Term Mortality in Medicare Patients (≥65 Years) Treated With Ticagrelor Versus Prasugrel After Percutaneous Coronary Intervention (from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium)

doi:10.1016/j.amjcard.2017.08.009

The American Journal of Cardiology

Volume 120, Issue 11, 1 December 2017, Pages 1926-1932

https://doi.org/10.1016/j.amjcard.2017.08.009 Get rights and content

Ticagrelor and prasugrel were found to be superior to clopidogrel for the treatment of acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI); however, the comparative effectiveness of these 2 drugs remains unknown. We compared postdischarge outcomes among older patients treated with ticagrelor versus prasugrel after PCI for ACS. We linked clinical data from PCIs performed in older patients (age ≥65) for ACS at 47 Michigan hospitals to Medicare fee-for-service claims from January 1, 2013, to December 31, 2014, to ascertain rates of 90-day readmission and long-term mortality. We used propensity score matching to adjust for the nonrandom use of ticagrelor and prasugrel at discharge. Logistic regression and Cox proportional hazards models were used to compare rates of 90-day readmission and long-term mortality, respectively. Patients discharged on ticagrelor (n = 1,243) were more frequently older, female, had a history of cerebrovascular disease, and presented with ST- or non-ST-elevation myocardial infarction compared with prasugrel (n = 1,014). After matching (n = 756 per group), there were no significant differences in the rates of 90-day readmission (16.7% ticagrelor vs 14.6% prasugrel; adjusted odds ratio 1.15, 95% confidence interval 0.86 to 1.55, p = 0.35) or 1-year mortality (5.4% ticagrelor vs 3.7% prasugrel; hazard ratio 1.3, 95% confidence interval 0.8 to 2.2, p = 0.31). In conclusion, we found no significant differences in the rates of 90-day readmission or long-term mortality between older patients treated with ticagrelor and patients treated with prasugrel after PCI for ACS. In the absence of randomized data to the contrary, these 2 treatments appear similarly effective.

Section snippets

Methods

We performed a retrospective analysis on data collected by the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2), a registry of all patients who underwent PCI in the state of Michigan. This is a prospective, multicenter, statewide registry of patients who underwent PCI at any nonfederal hospital in Michigan. A more detailed description of the registry, including data collection and auditing practices, has been described previously.9, 10 For the present study, we evaluated

Results

From January 1, 2013, to December 31, 2014, a total of 13,702 Medicare patients who underwent PCI were discharged alive on clopidogrel, ticagrelor, or prasugrel at 47 hospitals in Michigan. Of these patients, 10,261 were discharged on clopidogrel and were excluded. After further exclusions including those aged <65 years old, there were 1,243 patients in the ticagrelor group and 1,014 patients in the prasugrel group (Figure 1). Baseline characteristics of the unmatched and matched cohorts are

Discussion

In this retrospective observational study examining patients discharged on ticagrelor or prasugrel after undergoing PCI for ACS, we found no significant differences in the rates of 90-day readmission and 1-year mortality among matched patients. After excluding patients with absolute or relative contraindications to prasugrel in a sensitivity analysis, we found no significant differences in the rates of readmission or mortality.

There is reason to believe that there may be important differences

Acknowledgment

The authors are indebted to all the study coordinators, investigators, and patients who participated in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry.

Disclosures

Hitinder S. Gurm receives research funding from Blue Cross Blue Shield of Michigan and the National Institutes of Health and is a consultant for Osprey Medical. None of the authors have any conflicts directly relevant to this study.

References (26)

G.W. Yost et al.
Readmission in the 30 days after percutaneous coronary intervention
JACC Cardiovasc Interv
(2013)
L.A. Herrel et al.
Identifying drivers of episode cost variation with radical prostatectomy
Urology
(2016)
M. Iskedjian et al.
Relationship between daily dose frequency and adherence to antihypertensive pharmacotherapy: evidence from a meta-analysis
Clin Ther
(2002)
YeX. et al.
Association between copayment and adherence to statin treatment initiated after coronary heart disease hospitalization: a longitudinal, retrospective, cohort study
Clin Ther
(2007)
L. Wallentin et al.
Ticagrelor versus clopidogrel in patients with acute coronary syndromes
N Engl J Med
(2009)
S.D. Wiviott et al.
Prasugrel versus clopidogrel in patients with acute coronary syndromes
N Engl J Med
(2007)
Z. Motovska et al.
Prasugrel versus ticagrelor in patients with acute myocardial infarction treated with primary percutaneous coronary intervention: clinical perspective
Circulation
(2016)
C. Larmore et al.
“Real-world” comparison of prasugrel with ticagrelor in patients with acute coronary syndrome treated with percutaneous coronary intervention in the United States
Catheter Cardiovasc Interv
(2016)
R. Beigel et al.
Real-world use of novel P2Y12 inhibitors in patients with acute myocardial infarction: a treatment paradox
Cardiology
(2016)
WuC. et al.
Risk stratification for long-term mortality after percutaneous coronary intervention
Circ Cardiovasc Interv
(2014)

E.J. Benjamin et al.

Heart Disease and Stroke Statistics—2017 Update: a report from the American Heart Association

Circulation

(2017)

E. Kline-Rogers et al.

Development of a multicenter interventional cardiology database: the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) experience

J Intervent Cardiol

(2002)

M. Moscucci et al.

Association of a continuous quality improvement initiative with practice and outcome variations of contemporary percutaneous coronary interventions

Circulation

(2006)

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Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis
2023, American Journal of Cardiology
Limited data comparing prasugrel and ticagrelor in acute coronary syndrome are available. Online databases, including MEDLINE and Cochrane Central, were queried to compare these drugs. The primary outcomes of this meta-analysis are myocardial infarction (MI), all-cause mortality, cardiovascular mortality, noncardiovascular mortality, stent thrombosis, and stroke. The secondary outcome is major bleeding. A total of 9 studies, including 94,590 patients (prasugrel group = 32,759; ticagrelor group = 61,831), were included in this meta-analysis. The overall mean age was 62.73 years, whereas the mean age for the ticagrelor and prasugrel groups was 63.80 and 61.65 years, respectively. Prasugrel is equally effective as compared with ticagrelor in preventing MI. There was no difference between the 2 groups regarding all-cause mortality, stent thrombosis, stroke, or major bleeding. In patients with acute coronary syndrome, prasugrel is equally effective when compared with ticagrelor in preventing MI.
Rates of 30-Day and 90-Day Readmission Between Genotype-Optimal and Genotype-Suboptimal Antiplatelet Therapy Prescribing After Percutaneous Coronary Intervention
2023, American Journal of Cardiology
Current evidence increasingly supports CYP2C19 genotype-guided P2Y₁₂ inhibitor selection. Clopidogrel remains the most prescribed P2Y₁₂ inhibitor despite higher readmission rates than those of more efficacious third-generation P2Y₁₂ inhibitors. It remains unclear whether pharmacogenetically (PGx)-guided antiplatelet therapy directly reduces readmissions after percutaneous coronary intervention (PCI). A single-center retrospective observational cohort study at a tertiary academic medical center was conducted. Patients receiving CYP2C19 genotyping after PCI were included and stratified into 2 groups (PGx-optimal vs PGx-suboptimal P2Y₁₂ inhibitor prescribed) on the basis of CPIC (Clinical Pharmacogenetics Implementation Consortium) recommendations. Primary outcomes included 30-day and 90-day readmissions after index PCI. Most patients (78%) were of non-European ancestry. Among patients receiving PGx-optimal therapy, 50% had acute coronary syndromes whereas 61% receiving PGx-suboptimal therapy had stable coronary artery disease. Comparable 30-day (12% vs 10%, p = 0.481) and 90-day readmission rates (24% vs 28%, p = 0.323) were observed between patients receiving PGx-optimal or PGx-suboptimal therapies. PGx-optimal therapy was associated with fewer emergency department visits (3.4% vs 4.0%, p = 0.021) within 30 days, and patients initially prescribed PGx-suboptimal therapy were switched more often to PGx-optimal therapy during a readmission than were patients prescribed PGx-suboptimal antiplatelet therapy (p <0.001). In conclusion, CYP2C19 genotype-guided P2Y₁₂ inhibitor therapy did not improve 30- and 90-day all-cause readmission rates in a predominantly non-European population. However, P2Y₁₂ inhibitor therapy became concordant with CYP2C19 genotype in approximately half of patients during the first readmission after PCI, which may present further opportunities to revisit and optimize dual antiplatelet therapy in patients who undergo PCI.
Readmissions to Hospital After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Factors Associated with Readmissions
2020, Cardiovascular Revascularization Medicine
Citation Excerpt :
The change based on the proposal of the Bundle Payment for Care Improvement Initiative could have substantial financial impact there could be potentially more readmissions with financial penalties. We found only one study of 90-day readmissions which took place in a Medicare cohort [40] and further work on 90-day readmissions is needed. In conclusion, readmissions after PCI are an important problem in contemporary PCI.
Readmissions after PCI are a burden to patients and health services that are not well understood.
A systematic review was performed to identify studies of readmission after PCI. Readmission rates and causes of readmission were examined and factors associated with 30-day readmissions were combined using meta-analyses.
A total of 39 studies evaluated readmissions after PCI (6,569,690 patients, 31 studies). The 30-day readmission rate varied from 3.3%–15.8%. Beyond 30-days, the readmission rate was 6% at 2 months, 31.5% at 6 months, 18.6–50.4% at 12 months and 26.3–71% beyond 48 months. The pooled proportion of patients with cardiac cause for readmissions ranged from 4.6%–75.3%. The range of rates of 30-day readmissions for reinfarction/stent thrombosis, heart failure, chest pain and bleeding were 2.5%–9.5%, 5.9%–12%, 6.7–38.1% and 0.7–7.5%, respectively. Meta-analysis suggests that female gender (RR 1.25(1.20–1.30), I² = 65.2%), diabetes (RR 1.22(1.20–1.25), I² = 0%), heart failure (RR 1.43(CI 1.28–1.60), I² = 92.8%), renal failure (RR 1.50(1.45–1.55), I² = 0%), chronic lung disease (RR 1.34(1.26–1.44), I² = 87.5%), peripheral artery disease (RR 1.20(1.15–1.25), I² = 46.5%) and cancer (RR 1.35(1.15–1.58), I² = 72.8%) were associated with 30-day readmissions. The average cost of unplanned and all 30-day readmissions has been reported to be $12,636 and $17,576, respectively.
We estimate that 1 in 7 patients who undergo PCI are readmitted within 30-days and the rate can rise to up to 3 in 4 patients beyond 3 years. Interventions should be considered to reduce readmissions such as discharge checklists, evaluation of medication compliance at follow-up and prompt management when patients re-present to emergency department.
Prevalence, long-term prognosis and medical alternatives for patients admitted for acute coronary syndromes and prasugrel contraindication
2018, International Journal of Cardiology
Citation Excerpt :
In order to minimize that ticagrelor was not assigned after a randomization phase we obtained a subset of paired patients, by propensity score matching, to perform the last analyses that aimed to assess the effect of ticagrelor on patients with prasugrel contraindication. This methodology has been largely described and it equates group characteristics using defined variables in order to analyze the effect of a single variable or treatment [25, 26]. Prasugrel and ticagrelor were firstly used in 2010 in both centers and, therefore, for this analysis only patients admitted between 2010 and 2016 were included, what resulted in a subset of 3816 patients.
Prasugrel is a potent antiplatelet therapy that has demonstrated to be superior to clopidogrel for patients with acute coronary syndromes (ACS) but has three main contraindications.
Prospective study of all patients admitted for ACS in two hospitals. Prasugrel contraindication group was defined by the presence of age >75 years, weight <60 kg or previous stroke. We also performed a propensity score matching to obtain a well-balanced subset of patients with the same probability of receiving ticagrelor.
We included 8207 patients and 2538 (30.9%) had any contraindication for prasugrel, being age >75 years the most frequent (29.0%). Hospital mortality was 4.4% and it was >2-fold higher in patients with any contraindication for prasugrel (7.9% vs. 2.8%; p < 0.01). Postdischarge follow-up (median 59.9 months) revealed that patients with prasugrel contraindication had higher cardiovascular and all-cause mortality as well as a first major cardiovascular event (MACE). No differences in bleeding rates were found in patients with vs. without prasugrel contraindication. Prasugrel contraindication was independently associated to higher cardiovascular (HR: 1.42) and all-cause mortality (HR: 1.47), as well as higher MACE (HR: 1.25). In the sub-cohort of 482 pairs of patients, obtained by a propensity score matching, ticagrelor treatment was associated with lower cardiovascular death (HR: 0.22), all-cause mortality (HR: 0.30) and first MACE (HR: 0.58) in patients with prasugrel contraindication.
Almost one third of ACS patients have prasugrel contraindications and they have worst in in-hospital and post-discharge prognosis. Ticagrelor improved postdischarge outcomes in patients with prasugrel contraindications.
1-Year Outcomes of Patients Undergoing Primary Angioplasty for Myocardial Infarction Treated With Prasugrel Versus Ticagrelor
2018, Journal of the American College of Cardiology
Citation Excerpt :
Considering the differences in the risk characteristics of patients treated with prasugrel and those treated with ticagrelor, the relevance of this comparison is limited (18). After matching for risk profile, no significant difference in 1-year mortality between prasugrel and ticagrelor was reported among patients ≥65 years of age who were discharged from the hospital after PCI for acute coronary syndromes (5.4% ticagrelor vs. 3.7% prasugrel; HR: 1.3; 95% CI: 0.8 to 2.2; p = 0.31) (19). Switching between P2Y12 inhibitors occurs commonly in clinical practice.
Early outcomes of patients in the PRAGUE-18 (Comparison of Prasugrel and Ticagrelor in the Treatment of Acute Myocardial Infarction) study did not find any significant differences between 2 potent P2Y₁₂ inhibitors.
The 1-year follow-up of the PRAGUE-18 study focused on: 1) a comparison of efficacy and safety between prasugrel and ticagrelor; and 2) the risk of major ischemic events related to an economically motivated post-discharge switch to clopidogrel.
A total of 1,230 patients with acute myocardial infarction (MI) treated with primary percutaneous coronary intervention were randomized to prasugrel or ticagrelor with an intended treatment duration of 12 months. The combined endpoint was cardiovascular death, MI, or stroke at 1 year. Because patients had to cover the costs of study medication after hospital discharge, some patients decided to switch to clopidogrel.
The endpoint occurred in 6.6% of prasugrel patients and in 5.7% of ticagrelor patients (hazard ratio: 1.167; 95% confidence interval: 0.742 to 1.835; p = 0.503). No significant differences were found in: cardiovascular death (3.3% vs. 3.0%; p = 0.769), MI (3.0% vs. 2.5%; p = 0.611), stroke (1.1% vs. 0.7%; p = 0.423), all-cause death (4.7% vs. 4.2%; p = 0.654), definite stent thrombosis (1.1% vs. 1.5%; p = 0.535), all bleeding (10.9% vs. 11.1%; p = 0.999), and TIMI (Thrombolysis In Myocardial Infarction) major bleeding (0.9% vs. 0.7%; p = 0.754). The percentage of patients who switched to clopidogrel for economic reasons was 34.1% (n = 216) for prasugrel and 44.4% (n = 265) for ticagrelor (p = 0.003). Patients who were economically motivated to switch to clopidogrel had (compared with patients who continued the study medications) a lower risk of major cardiovascular events; however, they also had lower ischemic risk.
Prasugrel and ticagrelor are similarly effective during the first year after MI. Economically motivated early post-discharge switches to clopidogrel were not associated with an increased risk of ischemic events. (Comparison of Prasugrel and Ticagrelor in the Treatment of Acute Myocardial Infarction [PRAGUE-18]; NCT02808767)
Real-World Use and Outcomes of Oral Antiplatelets Among Patients with Acute Coronary Syndrome: A Retrospective Cohort Study
2022, Drugs - Real World Outcomes

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: Authorship declaration: All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors agree with the manuscript.

: Chris Song and Devraj Sukul contributed equally to the drafting and preparation of the manuscript. Hitinder Gurm and Milan Seth had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

: Dr. Sukul is supported by the National Institutes of Health T32 postdoctoral research training grant (T32-HL007853) Bethesda, Maryland. This work was supported by the Blue Cross Blue Shield of Michigan and Blue Care Network as part of the Blue Cross Blue Shield of Michigan Value Partnerships program. The funding source supported data collection at each site and funded the data-coordinating center but had no role in study concept, interpretation of findings, or in the preparation, final approval, or decision to submit the manuscript.

: Disclaimer: Although Blue Cross Blue Shield of Michigan (BCBSM) and BMC2 work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees.

: See page 1931 for disclosure information

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Ninety-Day Readmission and Long-Term Mortality in Medicare Patients (≥65 Years) Treated With Ticagrelor Versus Prasugrel After Percutaneous Coronary Intervention (from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium)

Section snippets

Methods

Results

Discussion

Acknowledgment

Disclosures

JACC Cardiovasc Interv

Urology

Clin Ther

Clin Ther

Ticagrelor versus clopidogrel in patients with acute coronary syndromes

N Engl J Med

Prasugrel versus clopidogrel in patients with acute coronary syndromes

N Engl J Med

Prasugrel versus ticagrelor in patients with acute myocardial infarction treated with primary percutaneous coronary intervention: clinical perspective

Circulation

“Real-world” comparison of prasugrel with ticagrelor in patients with acute coronary syndrome treated with percutaneous coronary intervention in the United States

Catheter Cardiovasc Interv

Real-world use of novel P2Y12 inhibitors in patients with acute myocardial infarction: a treatment paradox

Cardiology

Risk stratification for long-term mortality after percutaneous coronary intervention

Circ Cardiovasc Interv

Heart Disease and Stroke Statistics—2017 Update: a report from the American Heart Association

Circulation

Development of a multicenter interventional cardiology database: the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) experience

J Intervent Cardiol

Association of a continuous quality improvement initiative with practice and outcome variations of contemporary percutaneous coronary interventions

Circulation