Delay in Filling Post-PCI Clopidogrel Prescription Linked to Increased Death, MI

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Patients who delay filling their initial clopidogrel prescription after undergoing percutaneous coronary intervention (PCI) have a higher risk of mortality and readmission for myocardial infarction (MI) regardless of the type of stent they received, according to a Canadian registry study published online May 28, 2014, ahead of print in the Journal of the American Heart Association.

Methods
Nicholas L. Cruden, MBChB, PhD, of the University of Edinburgh (Edinburgh, United Kingdom), and colleagues looked at data on patients enrolled in the Cardiac Services BC registry who were treated with BMS (n = 12,030) or DES (n = 3,599) in British Columbia, Canada, from 2004 to 2006.
While the median duration from hospital discharge to filling an initial clopidogrel prescription was 1 day, 30% of DES patents and 31% of BMS patients failed to fill the prescription within 3 days. Patients with prescription delays were older and more likely to have suffered a STEMI during the index admission, and had more comorbidities than those who filled the prescription within 3 days.


 

 

 

 

 

Stent Type Not a Factor

At 2 years after the index procedure, 5% of patients in the DES cohort and 7% in the BMS cohort had died. Readmissions for MI were 6% in both groups. When delay periods were categorized, any delay in filling the first clopidogrel prescription was associated with death and readmission for MI as well as the combined endpoint in both stent groups (tables 1 and 2).

Table 1. DES Cohort: Event Risk at 2 Years

 

HR (95% CI)
>1 Day

HR (95% CI)
>3 Days

HR (95% CI)
>5 Days

Death

2.3 (1.6-3.4)

2.4 (1.7-3.4)

3.0 (2.0-4.3)

Readmission for MI

1.7 (1.2-2.3)

2.0 (1.5-2.7)

1.7 (1.2-2.4)

Death/MI

1.8 (1.4-2.3)

2.0 (1.6-2.6)

1.9 (1.5-2.5)


Table 2. BMS Cohort: Event Risk at 2 Years

 

HR (95% CI)
>1 Day

HR (95% CI)
>3 Days

HR (95% CI)
>5 Days

Death

2.1 (1.7-2.6)

2.2 (1.9-2.6)

2.1 (1.7-2.5)

Readmission for MI

1.7 (1.4-2.1)

1.8 (1.5-2.1)

1.7 (1.4-2.0)

Death/MI

2.0 (1.7-2.3)

2.0 (1.8-2.3)

1.9 (1.7-2.2)


Additionally, the excess risk associated with a delay in filling a first clopidogrel prescription was highest in the 30 days immediately after hospital discharge (HR 5.5; 95% CI 3.5-8.6 for mortality and HR 3.1; 95% CI 2.4-4.0 for recurrent admission for MI) regardless of stent type, although delay remained an independent predictor of these events beyond 30 days.

Unsurprisingly, patients who never filled a prescription for clopidogrel had the greatest mortality risk (HR 12.0; 95% CI 7.2-19.9; for DES and HR 5.1; 95% CI 4.0-6.6; for BMS).

Interventions May Improve Compliance

The study authors say the findings that nearly 1 in 3 patients delayed filling a first clopidogrel prescription are consistent with other studies.

They note that factors that determine medication compliance are complex and were not examined in this study. However, previous research has pointed to physician-related prescription discrepancies, older age, the number of medications taken, and problems with income and insurance coverage.

Steps that may help improve early compliance in filling prescriptions, Dr. Cruden and colleagues say, include:

  • Enhancing discharge planning
  • Educating patients
  • Simplifying regulatory hurdles
  • Ensuring early community pharmacy involvement

They also point out that a recent study of DES patients found that planned telephone follow-up at predetermined time points after PCI improved adherence to oral antiplatelet therapy at 1 year.

“Identifying strategies to avoid delays in obtaining a first community prescription for clopidogrel may lead to improved clinical outcomes in this population,” they conclude.

 


Source:
Cruden NL, Din JN, Janssen C, et al. Delay in filling first clopidogrel prescription after coronary stenting is associated with an increased risk of death and myocardial infarction. J Am Heart Assoc. 2014;Epub ahead of print.


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Disclosures
  • The study was supported by the Victoria Heart Institute Foundation.
  • Dr. Cruden reports no relevant conflicts of interest.

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