Unsafe antiplatelet use persists in PCI patients

By Eleanor McDermid

Contraindicated antiplatelet use is rare but persists in patients undergoing percutaneous coronary intervention (PCI), show US study data.

"Further efforts to curb the use of contraindicated antiplatelet medications in the cardiac catheterization laboratory are needed", say Geoffrey Barnes (University of Michigan Frankel Cardiovascular Center, Ann Arbor VA Medical Center) and co-researchers.

The team found that 17.6% of 64,294 patients who underwent PCI within the Veterans Affairs system had a contraindication to at least one antiplatelet agent.

Yet 6.5% of these patients (1.1% of the whole study population) received a contraindicated antiplatelet agent, either during PCI (92.5%) and/or at discharge (11.9%), the researchers report in Circulation: Cardiovascular Quality and Outcomes.

Eptifibatide was the most frequently given contraindicated antiplatelet agent, used in 13.7% of patients who had a contraindication to it - most often in patients with severe hypertension, previous intracranial haemorrhage or stroke within the preceding 30 days. Abciximab was the next most frequently given, in 4.6% of patients with contraindications.

Among patients with contraindications, those who received a contraindicated medication had higher unadjusted rates of periprocedural bleeding than those who did not, at 22.7% versus 9.4%, and of 30-day mortality, at 4.6% versus 2.5%.

After accounting for propensity to receive specific antiplatelet agents, patients given abciximab despite thrombocytopenia or stroke within the past 2 years had significantly increased risks of major periprocedural bleeding. Eptifibatide use in contraindicated patients was not significantly associated with outcomes, but the team notes that the hazard ratios were increased and the 95% confidence intervals were wide and did not exclude the possibility of harm.

"Although certain bailout situations in [ST-segment elevation myocardial infarction] care may necessitate the consideration of contraindicated medication use, this potential situation explained only 13% of all contraindicated medication use", observe Barnes et al.

They suggest that periprocedural use of contraindicated medications "may reflect the time-sensitive nature of these procedures and the need for verbal orders in this setting."

But they point out that even verbal orders could be checked against electronic medical records by other team members. "Empowering nurses or other care team [providers] to identify potential medication contraindications and bring those to the physician's attention is integral to safe patient-care delivery", they say.

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