Delay in filling first clopidogrel prescription after coronary stenting is associated with an increased risk of death and myocardial infarction

Nicholas L Cruden; Jehangir N Din; Christian Janssen; Reginald Smith; J David Hilton; W Peter Klinke; Ron G Carere; Simon D Robinson; Anthony Della Siega

doi:10.1161/JAHA.113.000669

Delay in filling first clopidogrel prescription after coronary stenting is associated with an increased risk of death and myocardial infarction

J Am Heart Assoc. 2014 May 28;3(3):e000669. doi: 10.1161/JAHA.113.000669.

Authors

Nicholas L Cruden¹, Jehangir N Din², Christian Janssen³, Reginald Smith³, J David Hilton³, W Peter Klinke³, Ron G Carere⁴, Simon D Robinson³, Anthony Della Siega³

Affiliations

¹ Royal Infirmary of Edinburgh, Edinburgh, UK (N.L.C.) University of Edinburgh, Edinburgh, UK (N.L.C.).
² Royal Bournemouth Hospital, Bournemouth, UK (J.N.D.).
³ Victoria Heart Institute Foundation, Victoria, British Columbia, Canada (C.J., R.S., D.H., P.K., S.D.R., A.D.S.).
⁴ Providence Health Care, Vancouver, British Columbia, Canada (R.G.C.).

Abstract

Background: Patients frequently experience difficulties with medication compliance after hospital discharge. We investigated the effect of a delay in filling a first clopidogrel prescription after hospital discharge on clinical outcomes subsequent to coronary stenting.

Methods and results: Hospital administrative, community pharmacy, and cardiac revascularization data were determined for all patients receiving a coronary stent in British Columbia 2004-2006 with follow-up out to 2 years. Cox's proportional hazard regression analysis, adjusting for baseline demographics and procedural variables, was performed to examine the effects of delay in filling a clopidogrel prescription after hospital discharge on clinical outcomes.Of 15 629 patients treated with coronary stents, 3599 received at least 1 drug-eluting stent (DES), whereas 12 030 received bare metal stents (BMS) alone. In total, 1064 (30%) and 3758 (31%) patients in the DES and BMS groups, respectively, failed to fill a prescription within 3 days of discharge (median, 1 day; interquartile range [IQR], 1 to 3). After regression analysis, a delay of >3 days was predictive of mortality and recurrent myocardial infarction (MI) irrespective of stent type (DES: hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.7 to 3.4; and HR, 2.0; 95% CI, 1.5 to 2.7, respectively, and BMS: HR, 2.2; 95% CI, 1.9 to 2.6; and HR, 1.8; 95% CI, 1.5 to 2.1, respectively). This excess hazard was greatest in the 30-day period immediately after hospital discharge (mortality: HR, 5.5; 95% CI, 3.5 to 8.6; and MI: HR, 3.1; 95% CI, 2.4 to 4.0, for all patients).

Conclusions: Delays in patients filling their first prescription for clopidogrel after coronary stenting are common and associated with adverse clinical outcomes, irrespective of stent type. Strategies to reduce delays have the potential to improve clinical outcomes.

Keywords: clopidogrel; death; myocardial infarction; percutaneous coronary intervention.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Aged
Clopidogrel
Drug-Eluting Stents* / statistics & numerical data
Female
Humans
Male
Medication Adherence / statistics & numerical data*
Middle Aged
Myocardial Infarction / epidemiology*
Myocardial Infarction / etiology
Percutaneous Coronary Intervention / methods
Percutaneous Coronary Intervention / mortality*
Percutaneous Coronary Intervention / statistics & numerical data
Platelet Aggregation Inhibitors / therapeutic use*
Proportional Hazards Models
Risk Factors
Ticlopidine / analogs & derivatives*
Ticlopidine / therapeutic use
Time Factors
Treatment Outcome

Substances

Platelet Aggregation Inhibitors
Clopidogrel
Ticlopidine