Analysis of pharmacotherapy practice in patients after myocardial infarction: results of a prospective open study «PROMETHEUS»

According to the guidelines of the Russian Society of Cardiology, dual antiplatelet therapy (DAPT) is a standard treatment regimen for the prevention of cardiovascular events in patients after myocardial infarction (MI). However, some deviations from standard treatment regimens can be noted when conducting pharmacoepidemiological studies of DAPT, in real clinical practice.

Aim: To analyse dual antiplatelet and antithrombotic therapy in patients after myocardial infarction in the Kaliningrad region at the outpatient stage of medical care.

Material and Methods. Analysis of drug therapy in 130 patients after MI was performed in five different study periods (visit 1-5). Visit 1 corresponded to the moment of patients’ discharge from hospital, and visits 2–5 were conducted at 1, 3, 6 and 12 months after hospitalization for myocardial infarction.

Results. It was found that 97.7% of patients were prescribed dual antiplatelet therapy after hospitalisation, but the frequency of DAPT use gradually decreased during the year, reaching 67.7% in 360 days after MI. However, some deviations from standard treatment regimens were observed: 13.3% of patients received acetylsalicylic acid (ASA) monotherapy, 6.7% of patients received clopidogrel only, 5.7% of patients received ticagrelor only, and 6.7% of patients did not receive antiplatelet therapy. The most common combination used for DAPT in all study periods was the combination of acetylsalicylic acid and ticagrelor (59.4–67.6%). Some deviations in the choice of antithrombotic therapy were also revealed: 2 patients received ticagrelor as a part of triple antithrombotic therapy. At the same time, the duration of triple antithrombotic therapy for the combination of acetylsalicylic acid + ticagrelor + rivaroxaban was 1 year with the optimal duration from 1 to 6 months for patients with high risk of stroke, and for patients with high risk of bleeding this period may be limited by the period of patient hospitalisation.

Conclusion. In the Kaliningrad region, the majority of patients (from 67.7 to 97.7%) after MI receive DAPT at different times of medical care, but after a year, significant deviations from standard therapy regimens were observed. Deviations were also revealed when analysing the use of antithrombotic therapy: the use of ticagrelor as part of triple antithrombotic therapy, as well as an increase in its duration. These changes indicate the necessity to identify and analyse these deviations.

1. Bodde M.C., van Hattem N.E., Abou R., Mertens B.J.A., van Duijn H.J., Numans M.E. et al. Myocardial infarction patients referred to the primary care physician after 1-year treatment according to a guideline-based protocol have a good prognosis. Neth. Heart J. 2019;27(11):550–558. https://doi.org/10.1007/s12471-019-01316-w

2. Erlikh A.D. Twelve months outcomes in patients with acute coronary syndrome, by the Nationale registry RECORD-3. Russian Journal of Cardiology. 2018;(3):23-30. (In Russ.). https://doi.org/10.15829/15604071-2018-3-23-30

3. Boytsov S.A., Shakhnovich R.M., Tereschenko S.N., Erlikh A.D., Kukava N.G., Pevsner D.V. et al. Features of antiplatelet therapy with P2Y12 receptor inhibitors in patients with myocardial infarction according to the Russian Register of Acute Myocardial Infarction REGION-MI. Kardiologiia. 2022;62(9):44-53. (In Russ.). https://doi.org/10.18087/cardio.2022.9.n2278

4. Boytsov S.A., Shakhnovich R.M., Erlikh A.D., Tereschenko S.N., Kukava N.G., Rytova Y.K. et al. Registry of Acute Myocardial Infarction. REGION-MI – Russian Registry of Acute Myocardial Infarction. Kardiologiia. 2021;61(6):41–51. (In Russ.). https://doi.org/10.18087/cardio.2021.6.n1595

5. Gimbel M., Qaderdan K., Willemsen L., Hermanides R., Bergmeijer T., de Very E. et al. Clopidogrel versus ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation acute coronary syndrome (POPular AGE): the randomised, open-label, non-inferiority trial. Lancet. 2020;395(10233):1374–1381. https://doi.org/10.1016/S01406736(20)30325-1

6. Sapina A.I., Lebedeva A.Yu., Savvinova P.P., Zorina E.A., Kolosova E.S., Vasilyeva E.Yu. Use of antiplatelet agents in patients after myocardial infarction followed up in Moscow outpatient clinics. Results of a non-interventional prospective study. Russian Journal of Cardiology. 2024;29(3):5813. (In Russ.). https://doi.org/10.15829/15604071-2024-5813

7. Golovanova E.D., Antonyuk E.A., Marshutin N.A., Zhukova N.A. Analysis of antiplatelet and anticoagulant therapy in patients with cardiovascular pathology in outpatient practice. Vestnik Smolenskoy Gosudarstvennoy Medicinskoy Akademii. 2021;20(1):87-93. (In Russ.). https://doi.org/10.37903/vsgma.2021.1.13

8. Jacobsen M.R., Engstrøm T., Torp-Pedersen C., Gislason G., Glinge C., Butt J.H. et al. Clopidogrel, prasugrel, and ticagrelor for all-comers with ST-segment elevation myocardial infarction. Int. J. Cardiol. 2021;342:15– 22. https://doi.org/10.1016/j.ijcard.2021.07.047

9. Tscharre M., Egger F., Machata M., Rohla M., Michael N., Neumayr M. etal. Contemporary use of P2Y12-inhibitors in patients with acute coronary syndrome undergoing percutaneous coronary intervention in Austria: A prospective, multi-centre registry. PLoS One. 2017;12(6):e0179349. https://doi.org/10.1371/journal.pone.0179349

10. Chulkov V.S., Chulkov V.S., Ektova N.A., Minina E.E., Zhmaylova S.V., Okonenko T.I. Antithrombotic therapy in cardiac surgery patients. Modern problems of science and education. 2023;4. (In Russ.). https://doi.org/10.17513/spno.32898

11. Washam J.B., Dolor R.J., Jones W.S., Halim S.A., Hasselblad V., Mayer S.B. et al. Dual antiplatelet therapy with or without oral anticoagulation in the postdischarge management of acute coronary syndrome patients with an indication for long term anticoagulation: a systematic review. J. Thromb. Thrombolysis. 2016;42(2):312. https://doi.org/10.1007/s11239-014-1094-1

12. Lip G.Y.H., Collet J.P., Haude M., Byrne R., Chung E.H., Fauchier L. et al. 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace. 2019;21(2):192–193. https://doi.org/10.1093/europace/euy174

13. Fiedler K.A., Maeng M., Mehilli J., Schulz-Schüpke S., Byrne R.A., Sibbing D. et al. Duration of triple therapy in patients requiring oral anticoagulation after drug-eluting stent implantation: The ISARTRIPLE Trial. J. Am. Coll. Cardiol. 2015;65(16):1619–1629. https://doi.org/10.1093/europace/euy174

14. Yasuda S., Kaikita K., Akao M., Ako J., Matoba T., Nakamura M. et al. Antithrombotic therapy for atrial fibrillation with stable coronary disease. N. Engl. J. Med. 2021;385(17):1632. https://doi.org/10.1056/nejmoa1904143

15. Storey R.F., Angiolillo D.J., Bonaca M.P., Thomas M.R., Judge H.M., Rollini F. et al. Platelet inhibition with ticagrelor 60 mg versus 90 mg twice daily in the PEGASUS-TIMI 54 trial. J. Am. Coll. Cardiol. 2016;67(10):1145–1154. https://doi.org/10.1016/j.jacc.2015.12.062

16. Jones W.S., Mulder H., Wruck L.M., Pencina M.J., Kripalani S., Muñoz D. et al. Comparative effectiveness of aspirin dosing in cardiovascular disease. N. Engl. J. Med. 2021;384(21):1981–1990. DOI: 10.1056/NEJMoa2102137