Outcomes According to Cardiac Catheterization Referral and Clopidogrel Use Among Medicare Patients With Non–ST‐Segment Elevation Myocardial Infarction Discharged Without In‐hospital Revascularization

Abstract

Background While use of P2Y12 receptor inhibitor is recommended by guidelines, few studies have examined its effectiveness among older non– ST ‐segment elevation myocardial infarction patients who did not undergo coronary revascularization. Methods and Results We included unrevascularized non– ST ‐segment elevation myocardial infarction patients ≥65 years discharged home from 463 ACTION Registry‐ GWTG hospitals from 2007 to 2010. Rates of discharge clopidogrel use were described for patients with no angiography, angiography without obstructive coronary artery disease ( CAD ; ≥50% stenosis in ≥1 vessel), and angiography with obstructive CAD . Two‐year outcomes were ascertained from linked Medicare data and included composite major adverse cardiac events (defined as all‐cause death, myocardial infarction readmission, or revascularization), and individual components. Outcomes associated with clopidogrel use were adjusted using inverse probability‐weighted propensity modeling. Of 14 154 unrevascularized patients, 54.7% (n=7745) did not undergo angiography, 10.6% (n=1494) had angiography without CAD , and 34.7% (n=4915) had angiography with CAD . Discharge clopidogrel was prescribed for 42.2% of all unrevascularized patients: 37.8% without angiography, 34.1% without obstructive CAD at angiography, and 51.6% with obstructive CAD at angiography. Discharge clopidogrel use was not associated with major adverse cardiac events in any group: without angiography (adjusted hazard ratio [95% CI ]: 0.99 [0.93–1.06]), angiography without CAD (1.04 [0.74–1.47]), and angiography with CAD (1.12 [1.00–1.25], P interaction =0.20). Conclusions We found no association between discharge clopidogrel use and long‐term risk of major adverse cardiac events among older, unrevascularized non– ST ‐segment elevation myocardial infarction patients. Clopidogrel use in this population requires further prospective evaluation.