DR. GRANGER: Peter, let’s say that you have an algorithm that features one of the newer P2Y12 antagonists, ticagrelor or prasugrel, because you believe that the trial results showing about a 15% to 20% additional reduction in major cardiac thromboembolic events is meaningful. You have that on your algorithm. Let’s say someone gets started in the ED on ticagrelor, and then they can’t afford it. What advice do you have to give to institutions around this problem where we start something, and then we either have to transition or they get sent home and their pharmacy benefits don’t cover it, and then they end up stopping the treatment. How do we deal with this?
DR. BERGER: I think that it is a very common issue, either because of price or other considerations. I will tell you—and again, I don’t have very strong data to support this belief and practice of mine—I believe that what is the best medication at the time of a presentation may change in the days, weeks, or months after an intervention.
Let me skip the price one for a moment, although that is an important consideration. For example, if I have a very noncompliant patient for whom a twice-a-day reversible P2Y12 inhibitor is going to be a challenge, I’m not going to recommend that. If that is what they were started on at the time of discharge, I may well change to a one-a-day irreversible P2Y12 inhibitor days, weeks, or months after the procedure. If the person develops a need, for example, for an anticoagulant, I’m not going to administer one of the more potent antiplatelet agents along with the anticoagulant.
Clinicians need to know how to switch antiplatelet therapy most safely. Sometimes you need to re-bolus the patient, and sometimes you don’t, and I would recommend that everyone get comfortable with knowing how to go from one P2Y12 inhibitor to another. But again, I believe that in a given patient, the drug believed to be optimal for that patient may change over time.
DR. GRANGER: That is a great point, and that probably should be part of a comprehensive ACS algorithm, to include what your institution recommends in terms of switching. Peter, one thing I was really impressed by when you were at Geisinger is you had a policy to improve adherence, especially during the highest risk period of stent thrombosis. For patients who’d undergone stents, they did not leave their hospital room to be discharged unless they had a supply in their hand of 30 days of a P2Y12 antagonist. Is that something that we should promote as a standard around the country, and are you doing that at Northwell?
DR. BERGER: We are in the process of trying to implement that at Northwell; I do think it should be done. It wasn’t only that we gave patients a 30-day supply of their P2Y12 inhibitor prior to discharge, but we gave a 30-day supply of other newly prescribed cardiac medications as well. But importantly, we also followed up at around 20 days and 25 days with phone calls and other sorts of reminders. Best available data suggest that we ended up with an unheard of 99% compliance rate at 3 months.
One of the motivators for us to launch this was we had an insurance company, and we were able to analyze billing data for the approximately 500,000 patients that we insured. We saw the frequency with which patients discharged after receiving a coronary stent filled their prescription on the day of discharge, the day after, 2 days after, 3 days after, and never. The results confirmed what we all know, that adherence to medication is very poor, that non adherence turns out to be enormously expensive if the patients suffers stent thrombosis and is not in the 20% or 30% or so patients who die suddenly from the stent thrombosis, but rather, is in the remaining 60% or 70% of patients who typically suffer a large MI. We targeted P2Y12 inhibitors first with this adherence initiative, and it couldn’t have gone better.
DR. GRANGER: Good. Tim, you brought this up as well; I wonder if you have any other comments. For example, it depends on which data source you look at, but let’s say for continuing P2Y12 antagonists after discharge until 1 year happens somewhere between 30% and 70% of patients with acute myocardial infarction. It is clearly a huge opportunity to improve adherence. What is your strategy on how to address that?
DR. HENRY: Another great point, and it is really important to understand your process and resources. At discharge, they vary considerably across the country. We’re participating in a trial called the Affordability and Real-World Antiplatelet Treatment Effectiveness after Myocardial Infarction Study (ARTEMIS) (NCT02406677), where the goal is to determine if covering co-pays makes a difference—half of the hospitals will get co-pays covered versus just standard of care.6,7
As we started the trial, we obtained background information from all of the hospitals about what they do to encourage compliance, both at discharge as well as long-term. It was shocking to me the variability in the approaches from institution to institution. Some had none and some had several, but I think it really demonstrated that this is an area that requires further study.
A second point about adherence is illustrated by the Persantine-Aspirin Reinfarction Study (PARIS).8 Disruption—which means the patient for some reason stops—is much more risky when patients make independent decisions than if the physician was involved, or if it was a temporary stop for a specific procedure. The decision made in conjunction with the cardiologist actually can be done very safely. When patients just stop it for other reasons—financial, or otherwise—it is more risky.
Patient education is of critical importance, and having a process in place with regular follow-up that emphasizes the importance of dual antiplatelet therapy is important. Can I touch back on another area that I think is really important, Chris?
DR. GRANGER: Yes.
DR. HENRY: Two other issues with non-STEMI are very challenging. Right now there is considerable controversy about how quickly a patient with a non-STEMI should undergo cardiac catheterization, and it varies dramatically from across the country. The average time in some institutions is less than 10 hours. In other institutions, it is 2 days. Having a standardized plan of how fast you get these people to the lab, I think is very important. There was a trial just recently that showed that if you actually have a cardiac catheterization in less than three hours, those patients did better than if it was 24 hours.9,10
While the data are somewhat conflicting, I would also say the earlier you get these patients to the lab and get them revascularized, the better it is in terms of discharge efficiency. If you can get patients to the lab within 10 hours, likely most of those patients go home the next day. If you don’t catheterize somebody for two days or three days, well then you automatically have a longer hospital stay, so cost effectiveness and hospital flow play a role as well.
The second point that it is controversial now, is which P2Y12 inhibitor to use, and should you pretreat? I think in STEMI, it is pretty clear you should get the P2Y12 inhibitor on as quickly as possible. In non-STEMI, it is a little less clear because about 10% of those patients will have multivessel disease and may need surgery. The question is, should you give the P2Y12 inhibitor before or at the time that you decide to do the PCI?
Then you also have a new intravenous P2Y12 inhibitor, cangrelor, which is available. Where should we use cangrelor? When should we pretreat? Should we pretreat? I think it is a challenging area, and that illustrates even if you had a really good protocol 6 months ago, new data, new things come along that make you constantly look at your protocols and consider whether you adjust them.
DR. GRANGER: Great point, and of course your strategy for the timing of catheterization strongly influences that, right? If you’re going straight to the catheterization lab with a non-STEMI and the patient hasn’t yet gotten a P2Y12 antagonist, then the trade-off is different than if you’re going to wait a day or so.
You bring up another key point, including for Deb and the ED, and that is that the length of stay now is becoming shorter and shorter. That really requires us to begin patient education earlier and earlier, because the last thing we want is somebody going home without understanding their treatment plan, because then they’re going to be much less likely to be adherent.
DR. DIERCKS: It is interesting, I think all of us would argue that the length of stay for people in the ED in particular is short for those going immediately to the catheterization lab. The overall length of stay in the ED is increasing because our hospitals are full a lot of times, which kind of adds another layer to your statement—I do think the ED can be used for education. The question is, who can do it? That is really where I think emergency physicians just don’t have the time unless there are pathways already created, and pamphlets available for the patients while they wait to go upstairs. Again, there are, in my mind, a lot of opportunities and hours that are spent not being as productive for patients while they wait for inpatient beds.
DR. GRANGER: Great. This has been a great discussion. I think this discussion has been incredibly useful to highlight the fact that all of us are going to need to be re-looking at our care pathways, algorithms for managing the patient with ACS in our institutions and health systems, because things are really changing. Length of stay is shortening. Deb, as you pointed out, ED stay may be increasing, it certainly is a big issue for us here, and our tools are changing with new biomarkers that will be coming available.
We’re in an era where providing more efficient care and shorter length of stay when safe is something that we all want to be doing. That increases both the need and the value for having institutional standardized approaches for how we manage these patients. We’ve talked about everything from EMS through hospital discharge, and out to a year later where the transitions provide important challenges and opportunities to improve how we provide care.
I would like to thank you Deb, Peter, and Tim, for a great discussion, and conclude our medical roundtable.