Clinical InvestigationAcute Ischemic Heart DiseaseUnderutilization of clopidogrel and glycoprotein IIb/IIIa inhibitors in non–ST-elevation acute coronary syndrome patients: The Canadian Global Registry of Acute Coronary Events (GRACE) experience
Section snippets
Study population
GRACE was established as a multinational, prospective registry to describe the epidemiology, treatment patterns, and clinical outcomes of an unselected population of patients with the entire spectrum of ACS. Details of GRACE have been published.12
In brief, patients entered in the registry had to be 18 years or older, alive at the time of presentation, and admitted with a presumptive diagnosis of ACS based on the history and at least one of the following: abnormal cardiac biomarkers,
Patient characteristics
Table I shows the baseline characteristics, medical history, and presenting clinical features of the study population (n = 5,806). Despite having a normal initial biomarker level, patients with unstable angina (UA) had a slightly but significantly higher GRACE RS on presentation, as compared with non–ST-elevation myocardial infarction (NSTEMI) patients (P < .001). Overall, 40.4% and 31.0% of the study patients were in the GRACE high-risk and intermediate-risk categories, respectively. With
Discussion
In this study of high-risk NSTE-ACS patients in Canada, we found considerable underutilization of GpIIb/IIIa inhibitors and clopidogrel despite published randomized trials and clinical practice guidelines. In particular, clopidogrel was underused in the conservatively managed patients, whereas GpIIb/IIIa inhibitors were infrequently administered early even among high-risk patients who subsequently underwent PCI.
Several randomized clinical trials have evaluated the efficacy of antiplatelet
Conclusion
In this contemporary NSTE ACS population, both clopidogrel and GpIIb/IIIa inhibitors were targeted toward patients treated with an invasive strategy but paradoxically toward the lower-risk group. In particular, clopidogrel appeared to be underused among conservatively managed patients despite its proven efficacy in this CURE-like population, whereas GpIIb/IIIa inhibitors were administered to only a minority of the high-risk patients with elevated biomarkers. Our findings emphasize the ongoing
Disclosures
Dr. Shaun G. Goodman, Speaker and consulting honoraria and research grant support from Key Pharmaceuticals, Bristol-Myers Squibb, Sanofi Aventis, Pfizer, and Key Schering. Dr. Robert C. Welsh, Honoraria from Astra Zeneca, Eli Lilly, Boeringher Ingelheim, sanofi-aventis, Johnson and Johnson, Hoffman LaRoche, Schering Plough. Dr. Shamir R. Mehta, Honoraria and research grants from GlaxoSmithKline and Sanofi-Aventis. Dr. Gilles Montalescot, Research Grants from: Bristol Myers Squibb,
Acknowledgements
We thank all the study coordinators, investigators, and patients who participated in GRACE and GRACE2. Dr Andrew Yan is supported by the Canadian Institutes of Health Research and a New Investigator Award from the Heart and Stroke Foundation of Canada.
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Increased Uptake of Guideline-Recommended Oral Antiplatelet Therapy: Insights from the Canadian Acute Coronary Syndrome Reflective
2014, Canadian Journal of CardiologyCitation Excerpt :The completed forms were scanned using TELEform, version 10.0 (Cardiff Software Inc, San Diego, CA) and data were stored in an electronic database and analyzed using SAS software, version 9.2 (SAS Institute, Cary, NC) at the CHRC. The use of ADPri therapy in phases I (73 hospitals) and III (82 hospitals) was compared with patient-level data collected from the Canadian Global Registry of Acute Coronary Events (GRACE; 1999-2007), Expanded GRACE (GRACE2; 2004-2007)4-7 and the CANadian Registry of Acute Coronary Events (CANRACE) (2008) (55 hospitals); 34 hospitals participating in the ACS Reflective Program had previously participated in the GRACE/CANRACE programs. From November 2011-November 2013, 3099 participants were enrolled from 83 hospitals.
Comparative effectiveness of clopidogrel in medically managed patients with unstable angina and non-ST-segment elevation myocardial infarction
2014, Journal of the American College of CardiologyCitation Excerpt :Less than one-half (36%) of medically managed patients with UA or NSTEMI were prescribed clopidogrel during the study period (2003 to 2008), even though it was given a Class I indication in the 2002 AHA/ACC guidelines (2). In similar patient populations, the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) registry reported clopidogrel adherence rates of 28% in 2002 and 53% in 2005 (13), the GRACE registry (Global Registry of Acute Coronary Events) reported almost 50% usage of clopidogrel in Canadian patients between 2003 and 2007 (17), and in the ACTION Registry-GWTG (Get With the Guidelines), 55% of medically managed patients with NSTEMI between 2009 and 2011 were discharged on clopidogrel (15). Both GRACE and CRUSADE demonstrated increasing use of clopidogrel for UA or NSTEMI over time (18,19).
Time from adenosine di-phosphate receptor antagonist discontinuation to coronary bypass surgery in patients with acute coronary syndrome: Meta-analysis and meta-regression
2013, International Journal of CardiologyCitation Excerpt :The updated ACC/AHA 2009 guidelines have modified this approach by stating that clopidogrel may be administrated “before or at the time of PCI”, in patients with NSTEACS, but they do not give any new evidence to support this changing recommendation [57]. The same paper, revising data coming from the wide population included in the GRACE [58] and CRUSADE [59] registries, underscores that clopidogrel is underused in patients with NSTEACS, and especially in the high risk subgroup, probably because of concerns about CABG-related bleeding. In the CRUSADE study, in spite of the national guidelines, 87% of clopidogrel-treated patients underwent CABG within 5 days after discontinuation of treatment.
Early clopidogrel use in non-ST elevation acute coronary syndrome and subsequent coronary artery bypass grafting
2011, American Heart JournalCitation Excerpt :In the CURE trial, low-, intermediate-, and high-risk patients all had significantly lower event rates with clopidogrel use, but the greatest and most significant benefit (4.8% absolute reduction, P < .004) was seen in the highest risk patients.7 Analysis of Canadian patients in the GRACE2 registry showed that clopidogrel is paradoxically given to lower risk patients with NSTE-ACS.25 Data from the Second Euro Heart Survey on Acute Coronary Syndromes showed that diabetic patients (a high-risk subgroup) with NSTE-ACS were given clopidogrel less frequently than nondiabetic patients.26
Variability in the Treatment of Non-ST-Segment Elevation Acute Coronary Syndrome and Its Consequences
2011, Revista Espanola de Cardiologia SuplementosInappropriate use of clinical practices in Canada: a systematic review
2022, CMAJ. Canadian Medical Association Journal