Real-World Analyses of the De-Escalation of Dual Antiplatelet Therapy in Treatment of Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention in Taiwan

Background: Dual antiplatelet therapy (DAPT) is the standard treatment for acute myocardial infarction (MI). This study aimed to investigate the use of DAPT and de-escalation after discharge in real-world practice among patients with acute MI undergoing percutaneous coronary intervention (PCI) in Taiwan. Methods: Using the Taiwan National Health Insurance Research Database, we included patients who received PCI for acute MI and survived to discharge with DAPT from 2011 to 2021. The choice of different P2Y12 inhibitors at discharge and de-escalation therapy after discharge were analyzed. Results: Overall, 58989 patients (mean age 61.9 ± 13.2 years, male 81.4%) were included. The initial use of aspirin plus ticagrelor (A + T) increased from 4.8% in 2013 to 73.2% in 2021 (p < 0.01). Switch to de-escalation therapy occurred in 52.7% of the A + T users at 9 months follow-up. Aspirin plus clopidogrel (A + C) and ticagrelor monotherapy were the most commonly used de-escalation therapies in the first 6 months. Multivariable logistic regression analysis demonstrated that older patients and those with non-ST-segment elevation MI, multi-vessel PCI, baseline bleeding risk and bleeding events during follow-up were more likely to receive ticagrelor monotherapy than A + C. Conclusions: A + T has become the major initial DAPT for patients with acute MI undergoing PCI in Taiwan, but de-escalation is not uncommon after discharge. Ticagrelor monotherapy was more likely to be prescribed than A + C in those with multi-vessel PCI or bleeding concern.