Prolonged dual antiplatelet therapy in stable coronary disease: comparative observational study of benefits and harms in unselected versus trial populations

Abstract

Objective: To estimate the potential magnitude in unselected patients of the benefits and harms of prolonged dual antiplatelet therapy after acute myocardial infarction seen in selected patients with high risk characteristics in trials.

Design: Observational population based cohort study.

Setting: PEGASUS-TIMI-54 trial population and CALIBER (ClinicAl research using LInked Bespoke studies and Electronic health Records).

Participants: 7238 patients who survived a year or more after acute myocardial infarction.

Interventions: Prolonged dual antiplatelet therapy after acute myocardial infarction.

Main outcome measures: Recurrent acute myocardial infarction, stroke, or fatal cardiovascular disease. Fatal, severe, or intracranial bleeding.

Results: 1676/7238 (23.1%) patients met trial inclusion and exclusion criteria ("target" population). Compared with the placebo arm in the trial population, in the target population the median age was 12 years higher, there were more women (48.6% v 24.3%), and there was a substantially higher cumulative three year risk of both the primary (benefit) trial endpoint of recurrent acute myocardial infarction, stroke, or fatal cardiovascular disease (18.8% (95% confidence interval 16.3% to 21.8%) v 9.04%) and the primary (harm) endpoint of fatal, severe, or intracranial bleeding (3.0% (2.0% to 4.4%) v 1.26% (TIMI major bleeding)). Application of intention to treat relative risks from the trial (ticagrelor 60 mg daily arm) to CALIBER's target population showed an estimated 101 (95% confidence interval 87 to 117) ischaemic events prevented per 10 000 treated per year and an estimated 75 (50 to 110) excess fatal, severe, or intracranial bleeds caused per 10 000 patients treated per year. Generalisation from CALIBER's target subgroup to all 7238 real world patients who were stable at least one year after acute myocardial infarction showed similar three year risks of ischaemic events (17.2%, 16.0% to 18.5%), with an estimated 92 (86 to 99) events prevented per 10 000 patients treated per year, and similar three year risks of bleeding events (2.3%, 1.8% to 2.9%), with an estimated 58 (45 to 73) events caused per 10 000 patients treated per year.

Conclusions: This novel use of primary-secondary care linked electronic health records allows characterisation of "healthy trial participant" effects and confirms the potential absolute benefits and harms of dual antiplatelet therapy in representative patients a year or more after acute myocardial infarction.

Fig 1 Selection of participants who survived one year or more after myocardial infarction (MI) from CALIBER, April 2005-March 2010

Fig 2 Proportion of patients prescribed drugs for secondary prevention from date of index MI (one year before study entry) and up to three years of follow-up adjusted for censoring (assuming continuous coverage between first and last prescriptions issued). ACEI=angiotensin converting enzyme inhibitors; ADP=adenosine diphosphate; ARBs=angiotensin II receptor blockers

Fig 3 Kaplan-Meier risks of ischaemic and bleeding events in CALIBER’s real world, high risk, and target populations of patients surviving one year or more after acute myocardial infarction

Fig 4 Kaplan-Meier risks of myocardial infarction/stroke/fatal cardiovascular disease for patient subgroups defined by age, diabetes, one or more previous acute MI, and renal disease (indicated by eGFR) in CALIBER “real world” population. Age adjusted except for age subgroup analyses. Multivariate adjustment included age (not for age subgroup analyses), sex, diabetes, more than one MI, and renal disease. Reported CVD risk at third year of follow-up for reference patient characteristics: age 71 (median age of study population), male, no diabetes, no more than one previous MI, and no chronic renal disease