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Coronary artery disease
Original research article
Implications of the PEGASUS-TIMI 54 trial for US clinical practice
  1. Steven M Bradley1,2,3,
  2. Gregory P Hess4,5,
  3. Patrick Stewart4,
  4. Ehrin J Armstrong3,6,
  5. Steven A Farmer7,
  6. Jason H Wasfy8,
  7. Javier Alfonso Valle6,
  8. Amneet Sandhu6 and
  9. Thomas M Maddox3,5
  1. 1 Minneapolis Heart Institute, Minneapolis, Minnesota, USA
  2. 2 VA Eastern Colorado and University of Colorado, Colorado, USA
  3. 3 Department of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado, USA
  4. 4 Symphony Health, Conshohocken, Pennsylvania, USA
  5. 5 LDI University of Pennsylvania, Philadelphia PA, USA
  6. 6 Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
  7. 7 George Washington University, Washington, DC, USA
  8. 8 Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Steven M Bradley; steven.bradley{at}allina.com

Abstract

Objectives This study aims to determine the proportion of real-world patients with myocardial infarction (MI) who would have been eligible for the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial Infarction 54) trial, to characterise their current use of P2Y12 inhibitors and to explore the estimated costs and ischaemic event consequences of increasing P2Y12 inhibitor use among these patients.

Methods In the US national ACTION Registry–GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines), we identified 273 328 patients with MI and determined the proportion that would have met the eligibility criteria for the PEGASUS trial. We described longitudinal P2Y12 inhibitor use among patients eligible for PEGASUS and estimated the cost and ischaemic consequences of increasing P2Y12 use among eligible patients.

Results A total of 112 222 (41.1%) patients with MI in ACTION Registry–GWTG met eligibility for the PEGASUS trial. Among 83 871 eligible patients with pharmacy claims data, 23 042 (27.5%) were on a P2Y12 inhibitor at 1 year, 9661 (11.5%) at 2 years and 5246 (6.3%) at 3 years, with the majority (79.2%) of these patients on clopidogrel. The use of ticagrelor in eligible patients not yet on a P2Y12 inhibitor at 1 year post-MI would cost an estimated US$885 000 per MI, stroke or cardiovascular death averted over a 3-year time horizon, while the use of clopidogrel would cost an estimated US$19 800 per ischaemic event averted.

Conclusion In contemporary clinical practice, a minority of patients are on a P2Y12 inhibitor beyond 1-year post-MI. Applying PEGASUS trial findings to clinical practice would result in a large increase in P2Y12 inhibitor use, with a cost per ischaemic event averted that is strongly influenced by the choice of therapy.

  • P2Y12
  • myocardial infarction
  • secondary prevention
  • cost

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/openhrt-2016-000580

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    Footnotes

    • Contributors SMB, GPH, PS and TMM worked on the design, analysis, data interpretation and manuscript writing. EJA, SAF, JAW, JAV and AS worked on the design, data interpretation and manuscript writing.

    • Competing interests GPH serves as a member of the Clinical Excellence Committee for Millennium Health and is an employee of Symphony Health, which has a collaborative agreement with the American College of Cardiology. EJA reports consulting for Merck. JHW serves on the New England Comparative Effectiveness Public Advisory Council, which conducts cost-effectiveness analyses of clinical interventions.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data available. Requests for ACTION-GWTG Data are managed by the American College of Cardiology.