Use of Contraindicated Antiplatelet Medications in Percutaneous Coronary Intervention

Contraindicated antiplatelet medications have been administered to patients who have undergone percutaneous coronary intervention (PCI), although the incidence is relatively rare, according to findings published in Circulation: Cardiovascular Quality and Outcomes.

Researchers gathered data from the Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking CART Program between 2007 and 2013 in an effort to assess contraindicated medication use and associated clinical outcomes in patients who receive PCI.

A total of 64 294 patients were included in the study; 11 315 (17.6%) had contraindications to common antiplatelet medications and 737 (6.5%) of these patients received a contraindicated medication. Primary outcomes included all-cause mortality and periprocedural major bleeding events at 30 days defined as occurring within 3 days of PCI along with 1 of the following: an event that occurred in a critical organ, a hemoglobin drop of 2 + g/dL, or any blood transfusion.

Among the medications, abciximab and eptifibatide were the most commonly used in the periprocedural setting. Abciximab was used in 17 patients with severe hypertension, 147 patients with thrombocytopenia, and 115 patients who had a previous stroke, among the 5736 patients who had at least 1 contraindication to the drug.

Meanwhile, eptifibatide was used in 49 patients with severe hypertension, 68 patients who had a previous intracranial hemorrhage, and 70 patients who had a previous stroke, among the 2518 patients who had at least 1 contraindication to the drug.

However, there was a decline in the overall use of both drugs in PCI between 2007 and 2013—6.9% to 3.0% for abciximab and 22.9% to 12.0% for eptifibatide (P<.001 for both).

Among patients with known contraindications, the estimated cumulative incidence of periprocedural major bleeding was 22.7% (95% confidence interval [CI]: 18.1-23.9) in patients who received a contraindicated mediation vs 9.4% (95% CI: 8.6-9.7) in patients who did not receive a contraindicated medication (P<.001).

Among those patients who received a contraindicated medication, the estimated incidence of 30-day mortality was 4.6% (95% CI: 3.0-6.0) vs 2.5% (95% CI: 2.2-2.8) among patients who did not receive a contraindicated medication (P=.01). Interestingly, there were no incidences of intracranial hemorrhages in patients were given abciximab despite having at least 1 contraindication.

However, abciximab was associated with a higher unadjusted risk of periprocedural major bleeding in patients with thrombocytopenia and in those patients who had a previous stroke (29.1% vs 11.9%; hazard ratio [HR]: 2.57; CI: 1.71-3.87 and 19.5% vs 7.8%; HR: 2.50; 95% CI: 1.78-3.52, respectively). In the propensity-weighted model for bleeding, these associations persisted for both patients with thrombocytopenia and previous stroke. However, the use of abciximab in these patients was not significantly associated with 30-day all-cause mortality in that propensity-weighted model.

“Although the overall rate of contraindicated medication use among patients with PCI is low (1.1%), this study highlights the problem of medication errors in the United States,” the authors wrote. “Importantly, these data illustrate that the use of contraindicated antiplatelet medications persist, despite high-profile reports and EMR [electronic medical records] built-in warnings.”

More efforts are needed to curtail the use of contraindicated antiplatelet medication in the PCI setting, they concluded.

Reference

Barnes GD, Stanislawski MA, Liu W, et al. Use of contraindicated antiplatelet medications in the setting of percutaneous coronary intervention. Insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circ Cardiovasc Qual Outcomes. 2016;9. doi: 10.1161/CIRCOUTCOMES.115.002043.