Study Evaluates Use of Contraindicated Medications among Veterans Undergoing Percutaneous Coronary Intervention
BACKGROUND:
Contraindicated medication use may occur during a percutaneous coronary intervention (PCI), as these procedures are often performed urgently, when patient data may not be readily available. Using data from VA's Clinical Assessment, Reporting, and Tracking (CART) program, which records medication data from all PCIs performed within VA, this study examined the use of contraindicated antiplatelet medications for 64,294 Veterans who underwent a PCI between 2007 and 2013. Investigators focused on five commonly used medications: prasugrel, ticagrelor, abciximab, eptifibatide, and tirofiban. Patients' receipt of periprocedural (before or during procedure) antiplatelet medication and discharge medication (within 90 days of procedure) was determined using CART and VA pharmacy data. VA data also was used to determine increased bleeding and 30-day mortality outcomes. In addition, investigators assessed patient demographics, comorbid conditions, and previous cardiac procedures.
FINDINGS:
- Of the 64,294 Veterans who underwent PCI, 11,315 (18%) had a known contraindication to at least 1 of 5 antiplatelet medications. Among these patients, 7% received a contraindicated medication in either the periprocedural setting or upon hospital discharge.
- Patients on contraindicated antiplatelet therapy showed a non-significant trend for greater risk of 30-day mortality (5% vs. 3% for patients without a contraindicated medication) and periprocedural major bleeding (23% vs. 9%).
- Abciximab and eptifibatide were the most commonly used medications in the periprocedural setting, and patients who received contraindicated abciximab experienced a 2-fold increased risk of major bleeding. However, between 2007 and 2013 there was a decline in the overall use of both abciximab and eptifibatide.
IMPLICATIONS:
- Use of contraindicated antiplatelet medications persists despite high-profile reports, though the rate of contraindicated medication use is lower in VA compared with U.S. community practice.
LIMITATIONS:
- Cath laboratory medication use was determined from provider documentation in the clinical record via CART. The lack of additional pharmacy data on cath laboratory medication use may lead to an underestimation of contraindicated medication use.
- This study was unable to determine if the use of contraindicated antiplatelet agents was associated with complex bail-out situations.
- CART may not capture all PCIs received by Veterans outside of a VA setting.
AUTHOR/FUNDING INFORMATION:
Drs. Maddox and Bradley were supported by HSR&D Career Development Awards. Drs. Maddox, Ho, and Bradley are part of HSR&D's Center of Innovation for Veteran-Centered and Value-Drive Care, Seattle/Denver, and Dr. Nallamothu is part of HSR&D's Center for Clinical Management Research (CCMR), Ann Arbor.
Barnes G, Stanislawski M, Liu W, Barón A, Armstrong E, Ho M, Klein A, Maddox T, Brahmajee K, Nallamouthu B, Rumsfeld J, Tsai T, and Bradley S. Use of Contraindicated Antiplatelet Medications in the Setting of Percutaneous Coronary Intervention: Insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circulation: Cardiovascular Quality and Outcomes. July 2016;9(4):
