Impact of Area-Level Socioeconomic Deprivation on Post-PCI Outcomes Stratified by P2Y12 Inhibitor Therapy

TL;DR

This study finds that socioeconomic deprivation affects post-PCI outcomes differently depending on the type of antiplatelet therapy used.

Contribution

The study is the first to show how social deprivation impacts outcomes based on specific antiplatelet therapy after PCI.

Findings

Higher socioeconomic deprivation increased major atherothrombotic events with clopidogrel.

Higher deprivation increased bleeding risk with alternative P2Y12 inhibitors like prasugrel or ticagrelor.

Social vulnerability metrics did not significantly affect outcomes after adjustment.

Abstract

Social deprivation influences postpercutaneous coronary intervention (PCI) outcomes, but whether it affects outcomes by antiplatelet therapy is unknown.

The impact of area-level social determinants of health on the effectiveness and safety of P2Y12 inhibitors following PCI was assessed.

Data were abstracted from electronic health records for adults who underwent PCI and clinical cytochrome P450 2C19 genotyping and received a P2Y12 inhibitor across 3 institutions. Social Deprivation Index (SDI) and Social Vulnerability Metric (SVM) were assigned using zip code tabulation areas. Multivariable Cox regression was used to evaluate the association between SDI and SVM (per unit increase) and risk for major atherothrombotic events (MAE) (death, myocardial infarction, stent thrombosis, ischemic stroke, or revascularization for unstable angina) and bleeding (Global Use of Strategies to Open Occluded Coronary Arteries Moderate-Severe) with clopidogrel and alternative therapy (eg, prasugrel or ticagrelor).

Overall, 3,141 patients (mean age: 63 years; 33% female; 68% with acute coronary syndrome) were included. In clopidogrel-treated patients (n = 1,852), SDI was associated with higher risk for MAE (adjusted HR: 1.009; 95% CI: 1.001-1.016; P = 0.018) but not bleeding (adjusted HR: 1.001; 95% CI: 0.990-1.012; P = 0.838). In patients on alternative therapy (n = 1,289), SDI was associated with a higher risk for bleeding (adjusted HR: 1.014; 95% CI: 1.001-1.028; P = 0.048), but not MAE (adjusted HR: 0.998; 95% CI: 0.988-1.007; P = 0.652). SVM was not significantly associated with adverse outcomes with clopidogrel or alternative therapy after adjustment.

Higher SDI was associated with an increased risk of MAE with clopidogrel and bleeding with alternative therapy following PCI. Whether addressing socioeconomic disparities improves P2Y12 inhibitor-related outcomes remains to be determined.

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