Characteristics of patients with acute ST-segment elevation myocardial infarction treated with different combinations of antiaggregation therapy: experience from the Croatian branch of the ISACS-CT Registry

    Authors

    Abstract

    **Background and Aim**: The relevance of dual antiplatelet therapy (DAPT) in acute ST-segment elevation myocardial infarction (STEMI) is well-established (aspirin and P2Y12 inhibitors). (1) The role of glycoprotein (GP) IIb/IIIa inhibitors in clinical practice is not completely defined. Administration in the event of thrombotic complications is considered reasonable, although there is no evidence for routine use in primary percutaneous coronary intervention (pPCI). The aim was to analyze early outcomes of STEMI patients (pts) in the Croatian branch of the ISACS-CT (International Registry of Acute Coronary Syndromes in Transitional Countries) registry, depending on received antiaggregation therapy. **Patients and Methods**: Data were gathered retrospectively from pts hospitalized between January 2012 to October 2017. The study included 2503 pts with acute coronary syndrome, from which 48.9% (n=1224) were diagnosed with STEMI. The patients were divided into 4 groups depending on administered antiaggregation therapy. **Results**: For 7.8% (n=96) pts antiaggregation therapy data were missing, and 5.8% (n=71) were not treated with DAPT. Remaining 1057 (86.4%) pts were analyzed. Aspirin was administered in 95% of pts in the first 24 hours. 41.9% (n=443) of pts were additionally treated with clopidogrel, 16.1% (n=170) with ticagrelor, 28.6% (n=302) with clopidogrel and eptifibatide, and 13.4% (n=142) with ticagrelor and eptifibatide (**Table 1**). The groups did not differ in comorbidities, while pts receiving eptifibatide had lower systolic blood pressure on admission. Patients treated with eptifibatide were more frequently male, smokers, of younger age, had more thrombotic complications seen on coronary angiography (predominantly distal embolisation and “no-reflow” phenomenon) and lower in-hospital mortality. In a multivariable regression model adjusted for age, gender, hypertension, diabetes, and pPCI, increasing age (OR=1.1), diabetes (OR=1.9) and pPCI (OR=0.5) remained relevant to in-hospital mortality. ### TABLE 1: Patients’ characteristics. | | **ASA+** **Clopidogrel** **(n=443)** | **ASA+** **Ticagrelor** **(n=170)** | **ASA+ Clopidogrel + Eptifibatide (n=302)** | **ASA + Ticagrelor + Eptifibatide (n=142)** | **p-value** | | --- | --- | --- | --- | --- | --- | | **Male gender, n (%)** | 296 (66.8) | 112 (65.9) | 224 (74.2) | 110 (77.5) | 0.020 | | **Age (IQR)** | 63 (53, 75) | 66 (55, 77) | 62 (54, 71) | 59 (52, 68) | 0.002 | | **Hypertension, n (%)** | 294 (68.9) | 119 (73.0) | 199 (66.6) | 91 (64.1) | 0.348 | | **Hypercholesterolemia, n (%)** | 179 (44.8) | 68 (43.0) | 150 (51.2) | 76 (54.3) | 0.085 | | **Diabetes mellitus, n (%)** | 106 (24.3) | 37 (22.3) | 51 (16.9) | 34 (23.9) | 0.106 | | **Chronic kidney disease, n (%)** | 32 (9.3) | 10 (6.1) | 23 (8.0) | 7 (5.0) | 0.344 | | **Smoking, n (%)** | 221 (55.4) | 87 (58.8) | 179 (61.9) | 96 (69.6) | 0.025 | | **HR median (IQR)** | 80 (70, 92) | 80 (71, 94) | 80 (70, 92) | 78 (66, 92) | 0.318 | | **SBP median (IQR)** | 138 (120, 150) | 135 (115, 153) | 130 (112, 145) | 130 (120, 150) | 0.017 | | **Creatinine (IQR)** | 95 (81, 112) | 83 (72, 101) | 93 (78, 111) | 81 (69, 95) | 2, n (%)** | 105 (31.1) | 48 (30.4) | 77 (25.8) | 31 (22.1) | 0.161 | | **PCI - number of treated lesions >1, n (%)** | 57 (19.6) | 38 (25.7) | 55 (18.9) | 26 (18.7) | 0.350 | | **Thrombotic complications, n (%)** | 29 (8.7) | 9 (6.0) | 48 (16.5) | 29 (20.7) | <0.001 | | **Distal coronary embolisation** | 3 (0.9) | 1 (0.7) | 12 (4.1) | 13 (9.3) | | | **“No-reflow” phenomenon** | 10 (3.0) | 3 (2.0) | 11 (3.8) | 5 (3.6) | | | **Other** | 16 (4.8) | 5 (3.3) | 25 (8.6) | 11(7.8) | | | **In-hospital mortality, n (%)** | 33 (7.4) | 14 (8.2) | 9 (3.0) | 5 (3.5) | 0.020 | [†] ASA - acetylsalicylic acid; IQR - interquartile range; HR - heart rate; SBP - systolic blood pressure; hsTnT - high-sensitive troponin T; LVEF - left ventricular ejection fraction; pPCI - primary percutaneous coronary intervention; PCI - percutaneous coronary intervention. **Conclusion**: STEMI patients that are young, male and smokers are more frequently treated with eptifibatide, likely due to a higher burden of thrombotic complications. Unlike the choice of antiaggregation therapy, increasing age, diabetes and non-invasive management of STEMI were associated with in-hospital mortality.

    Keywords

    acute coronary syndrome, ST-elevation myocardial infarction, antiaggregation therapy, percutaneous coronary intervention

    DOI

    https://doi.org/10.15836/ccar2019.211

    Literature

    1. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018 Jan 7;39(2):119–77. https://doi.org/10.1093/eurheartj/ehx393
    Cardiologia Croatica
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    Characteristics of patients with acute ST-segment elevation myocardial infarction treated with different combinations of antiaggregation therapy: experience from the Croatian branch of the ISACS-CT Registry

    Extended Abstract
    Issue9-10
    Published
    Pages211-212
    PDF via DOIhttps://doi.org/10.15836/ccar2019.211
    acute coronary syndrome
    ST-elevation myocardial infarction
    antiaggregation therapy
    percutaneous coronary intervention

    Authors

    Petra Mjehović*ORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Filip LončarićORCIDAugust Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
    Dora FabijanovićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Nina JakušORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Dorja SabljakORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Ines VinkovićORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Vedrana VlahovićORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Grgur SalaiORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Toni RadićORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Klara KlarićORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Saša PavasovićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Ivo PlanincORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Maja ČikešORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Davor MiličićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    *Correspondence email: petra.mjehovic@gmail.com

    Abstract

    **Background and Aim**: The relevance of dual antiplatelet therapy (DAPT) in acute ST-segment elevation myocardial infarction (STEMI) is well-established (aspirin and P2Y12 inhibitors). (1) The role of glycoprotein (GP) IIb/IIIa inhibitors in clinical practice is not completely defined. Administration in the event of thrombotic complications is considered reasonable, although there is no evidence for routine use in primary percutaneous coronary intervention (pPCI). The aim was to analyze early outcomes of STEMI patients (pts) in the Croatian branch of the ISACS-CT (International Registry of Acute Coronary Syndromes in Transitional Countries) registry, depending on received antiaggregation therapy. **Patients and Methods**: Data were gathered retrospectively from pts hospitalized between January 2012 to October 2017. The study included 2503 pts with acute coronary syndrome, from which 48.9% (n=1224) were diagnosed with STEMI. The patients were divided into 4 groups depending on administered antiaggregation therapy. **Results**: For 7.8% (n=96) pts antiaggregation therapy data were missing, and 5.8% (n=71) were not treated with DAPT. Remaining 1057 (86.4%) pts were analyzed. Aspirin was administered in 95% of pts in the first 24 hours. 41.9% (n=443) of pts were additionally treated with clopidogrel, 16.1% (n=170) with ticagrelor, 28.6% (n=302) with clopidogrel and eptifibatide, and 13.4% (n=142) with ticagrelor and eptifibatide (**Table 1**). The groups did not differ in comorbidities, while pts receiving eptifibatide had lower systolic blood pressure on admission. Patients treated with eptifibatide were more frequently male, smokers, of younger age, had more thrombotic complications seen on coronary angiography (predominantly distal embolisation and “no-reflow” phenomenon) and lower in-hospital mortality. In a multivariable regression model adjusted for age, gender, hypertension, diabetes, and pPCI, increasing age (OR=1.1), diabetes (OR=1.9) and pPCI (OR=0.5) remained relevant to in-hospital mortality. ### TABLE 1: Patients’ characteristics. | | **ASA+** **Clopidogrel** **(n=443)** | **ASA+** **Ticagrelor** **(n=170)** | **ASA+ Clopidogrel + Eptifibatide (n=302)** | **ASA + Ticagrelor + Eptifibatide (n=142)** | **p-value** | | --- | --- | --- | --- | --- | --- | | **Male gender, n (%)** | 296 (66.8) | 112 (65.9) | 224 (74.2) | 110 (77.5) | 0.020 | | **Age (IQR)** | 63 (53, 75) | 66 (55, 77) | 62 (54, 71) | 59 (52, 68) | 0.002 | | **Hypertension, n (%)** | 294 (68.9) | 119 (73.0) | 199 (66.6) | 91 (64.1) | 0.348 | | **Hypercholesterolemia, n (%)** | 179 (44.8) | 68 (43.0) | 150 (51.2) | 76 (54.3) | 0.085 | | **Diabetes mellitus, n (%)** | 106 (24.3) | 37 (22.3) | 51 (16.9) | 34 (23.9) | 0.106 | | **Chronic kidney disease, n (%)** | 32 (9.3) | 10 (6.1) | 23 (8.0) | 7 (5.0) | 0.344 | | **Smoking, n (%)** | 221 (55.4) | 87 (58.8) | 179 (61.9) | 96 (69.6) | 0.025 | | **HR median (IQR)** | 80 (70, 92) | 80 (71, 94) | 80 (70, 92) | 78 (66, 92) | 0.318 | | **SBP median (IQR)** | 138 (120, 150) | 135 (115, 153) | 130 (112, 145) | 130 (120, 150) | 0.017 | | **Creatinine (IQR)** | 95 (81, 112) | 83 (72, 101) | 93 (78, 111) | 81 (69, 95) | 2, n (%)** | 105 (31.1) | 48 (30.4) | 77 (25.8) | 31 (22.1) | 0.161 | | **PCI - number of treated lesions >1, n (%)** | 57 (19.6) | 38 (25.7) | 55 (18.9) | 26 (18.7) | 0.350 | | **Thrombotic complications, n (%)** | 29 (8.7) | 9 (6.0) | 48 (16.5) | 29 (20.7) | <0.001 | | **Distal coronary embolisation** | 3 (0.9) | 1 (0.7) | 12 (4.1) | 13 (9.3) | | | **“No-reflow” phenomenon** | 10 (3.0) | 3 (2.0) | 11 (3.8) | 5 (3.6) | | | **Other** | 16 (4.8) | 5 (3.3) | 25 (8.6) | 11(7.8) | | | **In-hospital mortality, n (%)** | 33 (7.4) | 14 (8.2) | 9 (3.0) | 5 (3.5) | 0.020 | [†] ASA - acetylsalicylic acid; IQR - interquartile range; HR - heart rate; SBP - systolic blood pressure; hsTnT - high-sensitive troponin T; LVEF - left ventricular ejection fraction; pPCI - primary percutaneous coronary intervention; PCI - percutaneous coronary intervention. **Conclusion**: STEMI patients that are young, male and smokers are more frequently treated with eptifibatide, likely due to a higher burden of thrombotic complications. Unlike the choice of antiaggregation therapy, increasing age, diabetes and non-invasive management of STEMI were associated with in-hospital mortality.

    Literature

    1. 1.
      Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018 Jan 7;39(2):119–77.DOI