Ticagrelor Utilization in Patients With Non-ST Elevation Acute Coronary Syndromes in Romania.

BACKGROUND: Dual antiplatelet therapy (DAPT) represents a major tool of non-ST elevation acute coronary syndrome (NSTE-ACS) management. The real-world usage of potent P2Y12 inhibitors within DAPT in middle-income countries is poorly described. STUDY QUESTION: To assess the factors that influence P2Y12 inhibitor choice at discharge in invasively managed NSTE-ACS patients, without an indication for oral anticoagulation, treated across Romania. STUDY DESIGN: The Romanian National NSTE-ACS Registry allows the consecutive enrollment of NSTE-ACS patients admitted in 11 (of 24) interventional centers reimbursed from public funds. MEASURES AND OUTCOMES: NSTE-ACS patients that received DAPT at discharge were identified. Deceased patients, those with an indication for oral anticoagulation or not receiving DAPT at discharge, were excluded. P2Y12 inhibitor choice was analyzed based on demographic, clinical, and invasive management characteristics. RESULTS: One thousand fifty (63 ± 10 years, 73% male) of 1418 patients enrolled between 2016 and 2019 were analyzed. The P2Y12 inhibitor pretreatment rate was 90%. Obstructive coronary artery disease was found in 95.3% of patients. 84.6% underwent percutaneous coronary interventions (PCIs). Single vessel PCI was reported in 84% of PCI patients. The clopidogrel usage rate was 49.6%, ticagrelor 50.0%, and prasugrel 0.4%. Overall, higher ticagrelor usage was associated with: non-ST elevation myocardial infarction (P 0.035), age below 65 (P < 0.001), prior treatment with ticagrelor (P < 0.001), PCI during admission (P < 0.001), and its full 12-month reimbursement (since November 2017). Reimbursement increased the use of ticagrelor from 23.7% in 2016-2017 to 56.9% in 2018-2019 (P < 0.001). In PCI patients, ticagrelor use was associated with PCI with stenting (P 0.016) and multivessel PCI (0.013). CONCLUSIONS: DAPT, P2Y12 inhibitor pretreatment, and single vessel PCI are the standards of care in invasively managed NSTE-ACS patients in Romania. Besides the clinical and invasive characteristics that favor its use, the full reimbursement of ticagrelor introduced in November 2017 doubled its yearly usage.

Antithrombotic Strategies in Invasively Managed Patients with Non-ST Elevation Acute Coronary Syndromes and Non-Valvular Atrial Fibrillation in Romania.

Introduction: Concomitant atrial fibrillation (AF) in non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients complicates the decision-making process regarding short- and long-term antithrombotic strategies. Patient profiles and usage rates of different antithrombotic combinations in this patient subgroup in Romania are poorly described. Premises and objectives: To describe the characteristics of invasively managed NSTE-ACS patients with AF (either known or newly diagnosed) compared to patients with no oral anticoagulation (OAC) indications, and analyze the rates and factors that influence the different antithrombotic regimens at discharge in AF patients. Material and methods: The Romanian National NSTE-ACS Registry allows the enrollment of invasively managed NSTE-ACS patients admitted in 11 interventional centers. Patients with non-valvular AF and no other OAC indication were identified and compared with patients with no indication for OAC. The antithrombotic strategy at discharge was analyzed based on demographic, clinical, and invasive management characteristics. Outcomes:A total of 1418 patients were enrolled between 2016 and 2019 out of which, 175 AF subjects and 1159 patients with no OAC indication were included in the analysis. Subjects with AF were older (70 ± 8.3 vs 62.9 ± 10.4 years, p <0.001) and more likely to have a GRACE score >140 (aOR 2.28, 95% CI 1.58-3.31, p<0.001), a history of heart failure (aOR 3.07, 95% CI 2.14-4.41, p <0.001), dementia or Alzheimer disease (aOR 3.45, 95% CI 1.11-10.68, p 0.032), and non-fatal major cardiovascular (CV) events during admission (aOR 6.71, 95% CI 1.61-27.94, p 0.009). Globally, triple antithrombotic therapy (TAT) was used in 52.5% of AF patients. 69% of PCI patients received TAT. One in four patients with AF did not receive OAC at discharge. Prior treatment with OAC was the strongest predictor for OAC usage at discharge (aOR 12.34, 95% CI 3.21-47.61, p<0.001). Conclusion: More than one in 10 NSTE-ACS patients have a concomitant non-valvular AF diagnosis. These patients are significantly older and are more likely to have significant CV and non-CV disease. Triple antithrombotic therapy is the most used antithrombotic strategy, especially in the PCI subgroup. One in four NSTE-ACS AF patients do not receive OAC at discharge.

The Romanian National Registry of non-ST Elevation Acute Coronary Syndromes - Design and Rationale.

Introduction:Non-ST segment elevation acute coronary syndromes (NSTE-ACS) form a large part of the number of annual emergency admissions in the Cardiology Departments in Romania, representing a significant burden on the health care system resources. The European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of NSTE-ACS patients represent ideal standards, which are difficult to implement, given the significant differences in the socio-economic climates of the various European Union countries, as the access to modern reperfusion techniques for NSTE-ACS patients, including Romania, is usually suboptimal. Objectives:The evaluate the current implementation state of the ESC recommended protocols for the diagnosis and treatment of NSTE-ACS patients in Romania. There are no data regarding the number of patients who benefit from modern revascularization techniques, the time intervals between symptom onset, positive diagnosis and revascularization procedures, and the impact of these strategies on in-hospital and one-year mortality Materials and methods:We support the development of an online National Registry of NSTE-ACS patients, in which data obtained from the in-hospital medical records of patients undergoing invasive management will be prospectively recorded. The platform will initially be accessible to 11 interventional centers, and will include patients diagnosed and treated according to local protocols. Patient status at one year after the acute event will also be recorded. The Registry will eventually be accessible to any center in Romania caring for NSTE-ACS patients. The recorded variables will be based on those with a significant impact on the time from symptom onset to the positive diagnosis, type of clinical presentation, appropriate treatment initiation and the type of applied treatment. Eexpected outcomes:Local clinical expertise, the number of treated patients and center-level technical barriers are expected to significantly influence the reported diagnostic and therapeutic measures. The performance of the various local in-hospital guidelines and transfer protocols between non-interventional and interventional centers will be analyzed, based on which recommendations and objectives can be defined in order to optimize the ESC guidelines implementation. Conclusion:The National Registry of non-ST elevation acute coronary syndromes will provide an essential tool that facilitates the implementation of optimal ESC guideline-driven diagnostic and treatment measures, by adapting its recommendations to the socio-economic status in Romania and ensuring the best possible outcomes for the NSTE-ACS patient.