Antiplatelet therapy changes for patients with myocardial infarction with recurrent ischemic events: Insights into contemporary practice from the TRANSLATE-ACS (treatment with ADP receptor inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary syndrome) study

Background--Guidelines recommend P2Y₁₂ inhibitor therapy for 1 year after myocardial infarction (MI), yet little guidance is provided on antiplatelet management for patients with recurrent ischemic events during that year. We describe changes in P2Y₁₂ inhibitor type among patients with recurrent ischemic events in the first year after MI. Methods and Results--The TRANSLATE-ACS (Treatment WithADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After AcuteCoronary Syndrome) study enrolled 12 365 patients with MI treated with percutaneous coronary intervention. We examined whether P2Y₁₂ inhibitor choice changed among patients with recurrent MI, stent thrombosis, and/or unplanned revascularization during the first year after MI, and modeled factors associated with P2Y₁₂ inhibitor intensification (changing clopidogrel to prasugrel or ticagrelor). In the first year after MI, 1414 patients (11%) had a total of 1740 recurrent ischemic events (771 recurrent MIs, 969 unplanned revascularizations, and 165 stent thromboses). Median time to the first recurrent ischemic event was 154 days (25th-75th percentiles, 55-287 days). Of those with recurrent ischemic events, 101 of 1092 (9.3%) occurring in clopidogrel-treated patients led to P2Y₁₂ inhibitor intensification. Recurrent events involving stent thrombosis or MI were the strongest factors associated with P2Y₁₂ inhibitor intensification, yet only 40% of patients with stent thrombosis and 14% of patients with recurrent MI had P2Y₁₂ inhibitor intensification. Increasing age and longer time from the index MI were associated with lower likelihood for intensification. Conclusions--Few patients after MI with a recurrent ischemic event who were taking clopidogrel switched to a more potent P2Y₁₂ inhibitor, even after stent thrombosis events. Specific guidance is needed for patients who have recurrent ischemic events, particularly when closely spaced.