We examined patients presenting with acute
myocardial infarction treated with
percutaneous coronary intervention at 233 US hospitals in the TRANSLATE-ACS observational study from April 2010 to October 2012. We developed a multivariable logistic regression model to identify factors associated with
prasugrel selection.
Prasugrel use rates and associated 1-year risk-adjusted major adverse cardiovascular events and Global Utilization of
Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) moderate/severe
bleeding outcomes were also examined in relation to predicted mortality and
bleeding using the validated Acute Coronary Treatment and Intervention Outcomes (ACTION) risk prediction scores. Among 11 969 patients, 3123 (26%) received
prasugrel at the time of
percutaneous coronary intervention. The strongest factors associated with
prasugrel use included
cardiogenic shock (odds ratio [OR] 1.68, 95% CI 1.25-2.26),
drug-eluting stent use (OR 1.45, 95% CI 1.31-1.62), and
ST-segment elevation myocardial infarction presentation (OR 1.23, 95% CI 1.12-1.35). Older age (OR 0.57, 95% CI 0.0.53-0.61), dialysis (OR 0.56, 95% CI 0.32-0.96), prior history of
stroke/
transient ischemic attack (OR 0.52, 95% CI 0.38-0.73), and interhospital transfer (OR 0.50, 95% CI 0.46-0.55) were associated with lowest
prasugrel selection.
Prasugrel was used less often than
clopidogrel in patients at higher predicted
bleeding risk (21.9% versus 29.7%, P<0.001). Yet paradoxically,
prasugrel was also less likely than
clopidogrel to be used in patients with higher predicted mortality risk (21.1% versus 30.2%, P<0.001). Adjusted
bleeding and outcomes events were similar among those receiving
prasugrel and
clopidogrel in the 4 subgroups of patients based on
bleeding risk and ischemic benefits.
CONCLUSIONS: