Background: The PEGASUS trial demonstrated a reduction in ischemic events following P2Y12 inhibition with ticagrelor among patients with a prior MI. The implications of these findings for clinical practice are unknown.
Methods: We sought to determine the proportion of real-world myocardial infarction (MI) patients who would have been eligible for the PEGASUS-TIMI 54 trial, to characterize their current use of P2Y12 inhibitors, and to explore the estimated costs and ischemic event consequences of increasing P2Y12 inhibitor use among these patients. In the U.S. national ACTION Registry-GWTG, We identified 273,328 MI patients and determined the proportion that would have met the eligibility criteria for the PEGASUS trial. We described longitudinal P2Y12inhibitor use among PEGASUS eligible patients and estimated the cost and ischemic consequences of increasing P2Y12 use among eligible patients.
Results: A total of 112,222 (41.1%) MI patients in ACTION Registry-GWTG met eligibility for the PEGASUS trial. Among 83,871 eligible patients with pharmacy claims data, 23,042 (27.5%) were on a P2Y12 inhibitor at 1 year, 9,661 (11.5%) at 2 years, and 5,246 (6.3%) at 3 years (see Figure), with the majority (79.2%) of these patients on clopidogrel. Use of ticagrelor in eligible patients not already on a P2Y12 inhibitor at 1-year post MI would cost an estimated $885,000 per myocardial infarction, stroke, or cardiovascular death averted over a 3-year time horizon, while use of clopidogrel would cost an estimated $19,800 per ischemic event averted.
Conclusions: In contemporary clinical practice, a minority of patients are on a P2Y12inhibitor beyond 1-year post-MI. Applying PEGASUS trial findings to clinical practice would result in a large increase in P2Y12 inhibitor use with a cost per ischemic event averted that is strongly influenced by the choice of therapy.