RWE-005 - ASSOCIATION BETWEEN BLEEDING RISK AND INITIAL P2Y12 INHIBITOR SELECTION AND DE-ESCALATION AMONG PATIENTS WITH ACUTE CORONARY SYNDROME (ACS) AND PERCUTANEOUS CORONARY INTERVENTION (PCI).

Y. Wang, L. Cavallari, J. Brown, T. Cameron, A. Winterstein; University of Florida, Gainesville, FL, USA.

Background: Evolving evidence on heterogeneity of treatment effects and bleeding risk across patient groups has impacted post-ACS/PCI treatment recommendations including suggestions to tailor more potent P2Y12 inhibitors to low bleeding risk patients or to de-escalate treatment during the maintenance period. We assessed whether bleeding risk affects initial and maintenance P2Y12 inhibitor selection or de-escalation (i.e., switch from ticagrelor or prasugrel to clopidogrel).

Methods: This retrospective cohort study using MarketScan® Commercial claims data (2016-2018) included adult P2Y12 inhibitor-naïve ACS/PCI patients followed from the first P2Y12 inhibitor dispensing up to 1 year. Major bleeding risk was measured using Academic Research Consortium for High Bleeding Risk criteria measured via medical encounter diagnosis codes. Age, sex, and copay were included with bleeding risk in logistic regression models that assessed the impact of baseline bleeding risk on initial P2Y12 choice, and Cox regression assessed the impact of bleeding risk & events during follow-up on de-escalation.

Results: Among 22,886 P2Y12 inhibitor users, bleeding risk was more prominent among clopidogrel initiators (42.3%) vs ticagrelor/prasugrel (35.1%) (adjusted odds ratio =1.32, 95% CI 1.25-1.43). Among 11,285 ticagrelor/prasugrel initiators, baseline bleeding risk was weakly associated with de-escalation (adjusted hazard ratio [aHR]=1.11, 1.01-1.22), but the occurrence of a bleeding event during follow-up, (90% major bleeding events) was a strong predictor of de-escalation (aHR=4.59, 3.67-5.75).

Conclusion: Major bleeding risk was a moderate predictor of initial P2Y12 inhibitor choice while having a bleeding event during follow-up was strongly associated with de-escalation.