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Results

Success of Educational Interventions in Antiplatelet Therapy in Acute Coronary Syndrome Amy Larkin, PharmD1, New York, NY; Michael LaCouture, MA1, Caroline Padbury, BPharm1; Deepak L. Bhatt, MD, MPH2;

1Medscape Education, New York, NY; 2Brigham and Women’s Hospital, Boston, MA

This curriculum of CME activities was supported by an independent educational grant from AstraZeneca Pharmaceuticals LP.

Source of Support

DisclosureReferences

Scan here to view this poster online.

Larkin, LaCouture, Padbury: Nothing to disclose.

Bhatt: Received grants for clinical research from: Amarin Corporation plc; AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Eisai Co., Ltd; Ethicon, Inc.; Medtronic, Inc.; Sanofi; The Medicines Company

Conclusion

This study demonstrated the success of a curriculum-style educational intervention using multimedia technology on improving knowledge and performance of cardiologists and PCPs in ACS management. Activity 2, focusing on guideline-based management of ACS, was the most effective, showing the confusion that still surrounds the updated guidelines and how they should be translated into practice.

Introduction

Among practitioners, interpretation of clinical trial data, value placed on particular end points, and preferences for individual antiplatelet agents run the gamut.1 Current biases or uncertainty regarding newer agents is reflected by infrequent use in clinical practice; it is estimated that only 10% to 15% of patients with acute coronary syndromes (ACS) who undergo percutaneous coronary intervention (PCI) are currently treated with a newer antiplatelet agent.2 Low levels of adoption of the newer agents suggest a reliance on conventional therapy that runs counter to study outcomes and the oft-cited problems of platelet response variability. In a recent Medscape CME program pretest evaluation, with the exception of cardiologists, other physicians were more likely to choose the standard dose of clopidogrel to treat a patient presenting with ST-segment elevation myocardial infarction (STEMI) than either of the newer oral antiplatelet agents,3 despite favorable outcomes with the next-generation drugs in this patient population.4,5 The impact of continuing medical education (CME) on improving knowledge and performance of physicians in ACS management across 2 domains was measured.

Educational Goals:

• Evaluate the need for dual antiplatelet therapy in patients with ACS

• Compare and contrast the safety/efficacy data of antiplatelet agents in patients with ACS, focusing on reduction in adverse cardiovascular outcomes, bleeding risk, drug interactions, and management prior to surgical intervention and throughout post-procedural care

• Apply recent updates to clinical guidelines on the evidence-based use of antiplatelet agents in the treatment of ACS

• Assess strategies to optimize antiplatelet therapy and tailor treatment for patients with ACS who are managed via coronary artery bypass grafting (CABG), PCI, or optimal medical therapy

outcomEs assEssmEnt:

• The effects of the education were assessed using Linked Learning Assessments (LLAs)

• An LLA compares individual participants’ paired responses to questions before exposure to educational content (pre-assessment questions) with responses to the same questions after participation in the educational activity (post-assessment questions)

• Only participants who answered every assessment question are included in this analysis

• Each question in the LLA is directly related to the learning objectives of the educational activity

• The domains measured included Recognizing Characteristics of Antiplatelet Therapies and Implementing Antiplatelet Strategies

statistical analysis:

• For all questions combined, the effect size was determined using Cohen’s D

• Effect sizes greater than 0.8 are large, between 0.8 and 0.4 are medium, and less than 0.4 are small

• A Pearson’s χ2 statistic was used to determine significance

• P values less than .05 indicate a statistically significant result

MethodsEducational intErvEntions:

• Cardiologists and primary care providers (PCPs) participatedin at least 1 of 3 online CME activities within a curriculum

activity 1: Applying Data to Practice: Expert Perspectives in ACS Management

• Video discussion with slides (0.25 AMA PRA Category 1 Credit(s)™)

activity 2: Guideline-Based Optimization of ACS Management: Breaking Down the Recent Updates

• Expert video lecture with slides (0.5 AMA PRA Category 1 Credit(s)™)

activity 3: Antiplatelet Therapy in ACS Patients Where CABG Is the Best Option

• Case-based panel discussion with slides (0.5 AMA PRA Category 1 Credit(s)™)

• All activities were housed as a collection on Medscape Education

• Content was developed with input from a steering committee consisting of expert faculty in the field of ACS management

1. Kern MJ. “Conversations in cardiology”: How do you pick the best antiplatelet drug—clopidogrel, prasugrel, ticagrelor for your PCI patient? Catheter Cardiovasc Interv. 2012;79:255-262.

2. Hermiller JB, Cohen DJ. Out with the old, in with the new: overcoming clinical inertia in ACS. Medscape Education Cardiology. March 12, 2015. http://theheart.medscape.org/viewarticle/771026 Accessed March 20, 2015.

3. Bates ER, James SK, Storey RF, Montalescot G. PCI guidelines 2011: focus on antiplatelet therapies. theheart.org. November 30, 2011. Medscape Education Professional Education Performance Report. September 2012. Data on file.

4. Montalescot G, Wiviott SD, Braunwald E, et al; TRITON-TIMI 38 investigators. Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet. 2009;373:723-731.

5. Steg PG, James S, Harrington RA, et al; PLATO Study Group. Ticagrelor versus clopidogrel in patients with ST-elevation acute coronary syndromes intended for reperfusion with primary percutaneous coronary intervention: A Platelet Inhibition and Patient Outcomes (PLATO) trial subgroup analysis. Circulation. 2010;122:2131-2141.

Which of the following is true regarding newer-generation P2Y12 antagonists?

domain 1: Recognizing Characteristics of Antiplatelet Therapies (Correct answers indicated with yellow background and *)

100%

80%

60%

40%

20%

0%

Overall P < 0.001Card P = 0.01PCP P <0.001

Cardiology Nonparticipant (n = 51) Cardiology Participant (n = 51)PCP Nonparticipant (n = 48) PCP Participant (n = 48)

Both prasugrel and clopidogrel are

irreversible inhibitors of P2Y12 receptors

Cangrelor has the most rapid onset of platelet

inhibition*

Ticagrelor may only be used following

catheterization when the decision to proceed with PCI has been reached

Prasugrel should be administered as a

pretreatment before catheterization

41%

25%

42%

27%39%

65%

40%

8% 10% 10%15% 19%

10%0%

35%

15%

Which of the following is accurate regarding the use of ticagrelor?

100%

80%

60%

40%

20%

0%

Overall P = .01Cardiologist P = .09PCP P = .05


Both ticagrelor and clopidogrel are

irreversible inhibitors of P2Y12 receptors

Ticagrelor is associated with more rapid onset

and a greater degree of platelet inhibition than

clopidogrel*

Both ticagrelor and clopidogrel

pharmacokinetics are influenced by genetic

variants in the cytochrome P450 2C19 gene

Ticagrelor may only be used following

catheterization when the decision to proceed with PCI has been reached

81%92%

48%

67%

1% 3% 3%

69%

31%

67%

37%26%

61%

30%

57%

4% 4% 3% 3%0%

16%23%

13% 13%23%

9% 10%0%

31%

53% 57%

73%

30%

16%20%

13%

6% 3% 3% 3%

73%

87%84% 83%

13%9% 10% 7% 9% 4% 3% 3%

4%8% 13% 12% 8%

0%

21% 15%8%

0%

17%

6%

100%

80%

60%

40%

20%

0%

Overall P < .001Cardiology P = .30PCP P < .001


High-dose clopidogrel (600 mg loading dose followed by 75 mg bid)

Prasugrel Ticagrelor* High-dose clopidogrel, prasugrel, and ticagrelor are all associated with similar mortality rates

relative to use of standard clopidogrel

6%0%

16% 16% 16%

28%

58%68%

14%

38%

12%16%

56%

8%

18%30%

Which of the following agents is associated with reversible platelet inhibition in this patient?

100%

80%

60%

40%

20%

0%

Overall P = .001Cardiology P = .05PCP P = .001


Clopidogrel Prasugrel Ticagrelor* Warfarin

1% 3% 3%

69%

31%

67%

37%26%

61%

30%

57%

4% 4% 3% 3%0%

16%23%

13% 13%23%

9% 10%0%

31%

53% 57%

73%

30%

16%20%

13%

6% 3% 3% 3%

73%

87%84% 83%

13%9% 10% 7% 9% 4% 3% 3%

4% 2%12% 14% 10%

38%

12%

70%

86%

28%

60%

16%12%

22%14%

0%

Which of the following do you recommend at this time for this patient?

100%

80%

60%

40%

20%

0%


Overall P < .001Cardiologist P < .001PCP P = .03

Resume DAPT therapy for 12 months*

Resume DAPT therapy for 3 months

Resume use of only aspirin for 12 months

No antiplatelet therapy is required postoperatively

44%

6% 6%

30%20%

50%

6%

18%

4% 0% 0%4% 6%

88%

48%

70%

casE 3:

• Called to see a 74-year-old male in the emergency department with 45 minutes of substernal chest pressure, which came on at rest

• History of hypertension, hypercholesterolemia, and diabetes. No history of angina.

• Exam: obese (BMI 31 kg/m2), blood pressure 166/84 mmHg, heart rate 104 bpm, normal cardiovascular exam

• Lab: creatinine 0.8 mg/dL, FPG 115 mg/dL, A1c 6.8%, total cholesterol 255 mg/dL, and troponin I elevated at 3.4 ng/mL

• ECG: ST segment depression in leads I, aVL, V2-V3

• Patient has received aspirin 325 mg PO, IV heparin bolus followed by continuous drip, and metoprolol 12.5 mg PO

• Patient undergoes coronary angiography, which reveals a proximal LAD 95% lesion; decision made to proceed with PCI of the LAD lesion

• During PCI, a coronary dissection occurs in the proximal LAD, and the lesion is unable to be crossed and intervened upon. Patient is stabilized, is free of chest discomfort, and is hemodynamically stable without evidence for heart failure. ECG reveals left anterior wall and septal hypokinesis, with ejection fraction estimated to be 45%. Viability testing reveals hibernating anterior myocardium with ongoing residual ischemia. The decision is made to proceed with CABG.

• The patient undergoes uneventful CABG with a left internal mammary artery graft to the LAD.

What would you recommend for this patient initially?

How would you manage this patient initially?

100%

80%

60%

40%

20%

0%


Overall P < .001Cardiologist P = .003PCP P = .001

Proceed with cardiac catheterization followed by addition of prasugrel once coronary anatomy

has been defined

Addition of ticagrelor now followed by planned

surgical revascularization in 2 to 3 days

Addition of prasugrel now followed by urgent cardiac

catheterization/PCI*

Addition of clopidogrel now followed by urgent cardiac

catheterization/PCI

1% 3% 3%

69%

31%

67%

37%26%

61%

30%

57%

4% 4% 3% 3%0%

16%23%

13% 13%23%

9% 10%0%

31%

53% 57%

73%

30%

16%20%

13%

6% 3% 3% 3%

73%

87%84% 83%

13%9% 10% 7% 9% 4% 3% 3%

52%

33%44%

8%

25%

54%44%

15% 15%4%

25%27%

10% 13% 12%19%

casE 1:

• Called to see 54-year-old man in the emergency department with 45 minutes of substernal chest pressure, which came on at rest

• History of hypertension, hypercholesterolemia, and type 2 diabetes (T2D)

• No history of angina but a history of a TIA 2 years ago

• Exam: obese (BMI 31 kg/m2), blood pressure 166/84 mm Hg, heart rate 104 bpm, and an otherwise normal cardiovascular exam

• Lab: creatinine 0.8 mg/dL, FPG 115 mg/dL, A1c 6.8%, total cholesterol 255 mg/dL, and troponin I elevated at 3.4 ng/mL

• ECG: ST segment depression in leads II, III, aVF

• Patient has received aspirin, iv heparin bolus followed by continuous drip, and metoprolol

casE 2:

• Called to see a 68-year-old woman in emergency department with a 1-hour history of a complaint of severe substernal chest pressure, with radiation down her left arm, shortness of breath, and diaphoresis

• History remarkable for hypertension, hypercholesterolemia, and ongoing tobacco use

• Prior MI 3 years ago and was noted at that time to have “blockages in 2 coronary blood vessels”

• ECG: 3-mm ST segment elevation in leads 1, aVL, V4-V6 with associated T wave inversion

• Exam: heart rate 104 bpm, blood pressure 95/62 mm Hg, oxygen saturation of 92% on room air, bibasilar rates on chest exam

• Lab: normal renal function and an elevated troponin I

• Patient has already received aspirin and IV heparin

100%

80%

60%

40%

20%

0%


Overall P < .001Cardiologist P = .001PCP P < .001

Addition of clopidogrel followed by cardiac

catheterization

Addition of ticagrelor followed by cardiac

catheterization*

Addition of prasugrel followed by cardiac

catheterization

Proceed to cardiac catheterization to define

coronary anatomy followed by the addition of

clopidogrel

15% 19%

44%

17%

52%

10%2% 2%

12%

58%

8%

46%

19%17%8%

71%

domain 2: Implementing Antiplatelet Strategies (Correct answers indicated with yellow background and *)

Which of the following agents has shown improved all-cause mortality and cardiovascular mortality relative to standard-dose clopidogrel

(300 mg loading dose followed by 75 mg daily) in this patient?

dEmoGraphics

NotesFor more information contact Amy Larkin, PharmD, Director of Clinical Strategy, Medscape, LLC, at [email protected].

theheart.org logo PRINT VERSION

Red c 24 m 100 y 100 k 25

Black c 75 m 68 y 67 k 90

ovErall EffEct of Education

CardiologyNonparticipants

(n = 51)

CardiologyParticipants

(n = 51)

PCPNonparticipants

(n = 48)

PCPParticipants

(n = 48)

Patients treated per month with ACS, mean 14 10 10 9

SpecialtyCardiologyFamily medicineGeneral practiceInternal medicine

100%

------

100%

------

--

60%0%

40%

--35%2%

63%


(n = 52)


(n = 52)

PCPNonparticipants

(n = 52)

PCPParticipants

(n = 52)



100%

------

100%

------

--

40%4%

56%

--40%4%

56%


(n = 50)


(n = 50)

PCPNonparticipants

(n = 50)

PCPParticipants

(n = 50)



100%

------

100%

------

--

58%0%

42%

--44%0%

56%

Activity 1: Applying Data to Practice: Expert Perspectives in Acute Coronary Syndrome Management

Activity 2: Guideline-Based Optimization of ACS Management: Breaking Down the Recent Updates

Activity 3: Antiplatelet Therapy in Patients With Acute Coronary Syndrome Where CABG Is the Best Option

Activity Format

Topic N Effect Size (d)

Multimedia Incorporating New Data into Practice

PCPs = 48 Cardiologists = 51

PCPs = Medium (0.66)Cardiologists = Medium (0.67)

Multimedia Guideline-Based Care PCPs = 52 Cardiologists = 52

PCPs = Large (0.83) Cardiologists = Large (1.0)

Multimedia Selecting Antiplatelet Therapy

PCPs = 50 Cardiologists = 50

PCPs = Large (0.98)Cardiologists = Medium (0.66)

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