Real-world practice perspectives of Indian clinicians on dual antiplatelet therapy optimization post percutaneous coronary intervention and utilization of aspirin clopidogrel fixed dose combination in secondary prevention: INDI PROLONG STUDY
DOI:
https://doi.org/10.18203/2320-6012.ijrms20263514Keywords:
Dual antiplatelet therapy, Percutaneous coronary intervention, Clopidogrel, Aspirin, Fixed-dose combinationAbstract
Background: Background: Dual antiplatelet therapy (DAPT) is post-percutaneous coronary intervention (PCI) to prevent thrombotic events. However, optimal duration and agent choice remain debated, particularly in Indian practice. This study explored real-world clinician perspectives on DAPT optimization and the use of aspirin–clopidogrel fixed-dose combinations (FDCs).
Methods: The INDI-PROLONG study was an anonymous, cross-sectional PAN India survey conducted between June 15 and August 15, 2024. A total of 301 clinicians, including cardiologists, consulting physicians, diabetologists, and other specialists, participated. The survey assessed DAPT prescription patterns, preferred regimens, determinants of duration, and perceptions of aspirin–clopidogrel FDCs.
Results: Of 301 clinicians, 259 (86.1%) routinely prescribed DAPT post-PCI. For high thrombotic risk patients, 165 (54.8%) favored >12 months of therapy, while 136 (45.2%) recommended 12 months. Clopidogrel + aspirin was most preferred (57.8%), followed by ticagrelor + aspirin (23.9%) and prasugrel + aspirin (15.6%). Clopidogrel was prescribed to 25–50% of eligible patients by 137 (45.5%) clinicians. Key factors influencing duration included bleeding risk (48.8%), guideline recommendations (39.5%), adherence (36.5%), and thrombotic risk (32.2%). Switching from ticagrelor to clopidogrel was mainly due to bleeding (56.5%) and adverse reactions (30.6%). Cardiologists favored prolonged therapy, while consulting physicians preferred standard 12-month durations. Regional variation was noted, with northern India showing a higher preference for extended DAPT.
Conclusion: Indian clinicians demonstrate varied DAPT strategies, balancing efficacy, safety, and accessibility. Clopidogrel + aspirin remains the dominant choice. Findings highlight the need for India-specific guidelines to optimize DAPT duration and agent selection based on real-world evidence.
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References
Sidhu NS, Rangaiah SKK, Ramesh D, Veerappa K, Manjunath CN. Clinical characteristics, management strategies, and in-hospital outcomes of acute coronary syndrome in a low socioeconomic status cohort: an observational study from urban India. Clin Med Insights Cardiol. 2020;14: 1179546820918897. DOI: https://doi.org/10.1177/1179546820918897
World Health Organization. Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018.
Prabhakaran D, Jeemon P, Roy A. Cardiovascular diseases in India: current epidemiology and future directions. Circulation. 2016;133(16):1605-20. DOI: https://doi.org/10.1161/CIRCULATIONAHA.114.008729
Gupta R, Gaur K. Epidemiology of acute coronary syndromes in India. In: Cardiovascular disease in India. Boca Raton: CRC Press; 2020. DOI: https://doi.org/10.1201/9780429025396-1
Mardikar HM, Deshpande NV, Admane P. Changing management of acute MI - perspectives from India. EuroIntervention. 2012;8(Suppl P):P55-61. DOI: https://doi.org/10.4244/EIJV8SPA10
Alexander T, Mehta S, Mullasari A, Nallamothu BK. Systems of care for ST-elevation myocardial infarction in India. Heart. 2012;98(1):15-17. DOI: https://doi.org/10.1136/heartjnl-2011-301009
Angiolillo DJ, Galli M, Collet JP, Kastrati A, O'Donoghue ML. Antiplatelet therapy after percutaneous coronary intervention. EuroIntervention. 2022;17(17):e1371-96. DOI: https://doi.org/10.4244/EIJ-D-21-00904
Cao D, Chandiramani R, Chiarito M, Claessen BE, Mehran R. Evolution of antithrombotic therapy in patients undergoing percutaneous coronary intervention: a 40-year journey. Eur Heart J. 2020;42(4):339-51. DOI: https://doi.org/10.1093/eurheartj/ehaa824
Capodanno D, Alfonso F, Levine GN, Valgimigli M, Angiolillo DJ. ACC/AHA versus ESC guidelines on dual antiplatelet therapy: JACC guideline comparison. J Am Coll Cardiol. 2018;72(23 Pt A):2915-31. DOI: https://doi.org/10.1016/j.jacc.2018.09.057
Prasad A, Herrmann J. Myocardial infarction due to percutaneous coronary intervention. N Engl J Med. 2011;364(5):453-64. DOI: https://doi.org/10.1056/NEJMra0912134
Moon JY, Franchi F, Rollini F, Angiolillo DJ. Evolution of coronary stent technology and implications for duration of dual antiplatelet therapy. Prog Cardiovasc Dis. 2018;60(4-5):478-90. DOI: https://doi.org/10.1016/j.pcad.2017.12.004
Gargiulo G, Valgimigli M, Capodanno D, Bittl JA. State of the art: duration of dual antiplatelet therapy after percutaneous coronary intervention and coronary stent implantation - past, present and future perspectives. EuroIntervention. 2017;13(6):717-33. DOI: https://doi.org/10.4244/EIJ-D-17-00468
Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367. DOI: https://doi.org/10.1093/eurheartj/ehaa909
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119-77. DOI: https://doi.org/10.5603/KP.2018.0041
Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, et al. 2014 ESC/EACTS guidelines on myocardial revascularization. EuroIntervention. 2015;10(9):1024-94. DOI: https://doi.org/10.4244/EIJY14M09_01
Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2016;37(3):267-315. DOI: https://doi.org/10.1093/eurheartj/ehv408
Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. J Am Coll Cardiol. 2016;68(10):1082-1115. DOI: https://doi.org/10.1016/j.jacc.2016.03.513
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. Circulation. 2011;124(23):e574-e651. DOI: https://doi.org/10.1161/CIR.0b013e31823ba622
Palmerini T, Biondi-Zoccai G, Della Riva D, Mariani A, Sabaté M, Smits PC, et al. Clinical outcomes with bioabsorbable polymer- versus durable polymer-based drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. J Am Coll Cardiol. 2014;63(4):299-307. DOI: https://doi.org/10.1016/j.jacc.2013.09.061
Navarese EP, Andreotti F, Schulze V, Kołodziejczak M, Buffon A, Brouwer M, et al. Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug eluting stents: meta-analysis of randomised controlled trials. BMJ. 2015;350:h1618. DOI: https://doi.org/10.1136/bmj.h1618
Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J. 2018;39(3):213-60. DOI: https://doi.org/10.1016/j.rec.2017.11.020
Udell JA, Bonaca MP, Collet JP, Lincoff AM, Kereiakes DJ, Costa F, et al. Long-term dual antiplatelet therapy for secondary prevention of cardiovascular events in the subgroup of patients with previous myocardial infarction: a collaborative meta-analysis of randomized trials. Eur Heart J. 2016;37(4):390-9. DOI: https://doi.org/10.1093/eurheartj/ehv443
Hahn JY, Song YB, Oh JH, Chun WJ, Park YH, Jang WJ, et al. Effect of P2Y12 inhibitor monotherapy vs dual antiplatelet therapy on cardiovascular events in patients undergoing percutaneous coronary intervention: the SMART-CHOICE randomized clinical trial. JAMA. 2019;321(24):2428-37. DOI: https://doi.org/10.1001/jama.2019.8146
Vranckx P, Valgimigli M, Jüni P, Hamm C, Steg PG, Heg D, et al. Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: a multicentre, open-label, randomised superiority trial. Lancet. 2018;392(10151):940-9. DOI: https://doi.org/10.1016/S0140-6736(18)31858-0
Watanabe H, Domei T, Morimoto T, Natsuaki M, Shiomi H, Toyota T, et al. Effect of 1-month dual antiplatelet therapy followed by clopidogrel vs 12-month dual antiplatelet therapy on cardiovascular and bleeding events in patients receiving PCI: the STOPDAPT-2 randomized clinical trial. JAMA. 2019;321(24):2414-27. DOI: https://doi.org/10.1001/jama.2019.8145
Mehran R, Baber U, Sharma SK, Cohen DJ, Angiolillo DJ, Briguori C, et al. Ticagrelor with or without aspirin in high-risk patients after PCI. N Engl J Med. 2019;381(21):2032-42. DOI: https://doi.org/10.1056/NEJMoa1908419
Khan SU, Singh M, Valavoor S, Khan MU, Lone AN, Khan MZ, et al. Dual antiplatelet therapy after percutaneous coronary intervention and drug-eluting stents: a systematic review and network meta-analysis. Circulation. 2020;142(15):1425-36. DOI: https://doi.org/10.1161/CIRCULATIONAHA.120.046308
Banerjee S, Angiolillo DJ, Boden WE, Murphy JG, Khalili H, Hasan AA, et al. Use of antiplatelet therapy/DAPT for post-PCI patients undergoing noncardiac surgery. J Am Coll Cardiol. 2017;69(14):1861-70. DOI: https://doi.org/10.1016/j.jacc.2017.02.012
Palmerini T, Sangiorgi D, Valgimigli M, Biondi-Zoccai G, Feres F, Abizaid A, et al. Short- versus long-term dual antiplatelet therapy after drug-eluting stent implantation: an individual patient data pairwise and network meta-analysis. J Am Coll Cardiol. 2015;65(11):1092-1102. DOI: https://doi.org/10.1016/j.jacc.2014.12.046
Li XY, Su GH, Wang GX, Hu HY, Fan CJ. Switching from ticagrelor to clopidogrel in patients with ST-segment elevation myocardial infarction undergoing successful percutaneous coronary intervention in real-world China: occurrences, reasons, and long-term clinical outcomes. Clin Cardiol. 2018;41(11):1446-54. DOI: https://doi.org/10.1002/clc.23074
Wang X, Xi S, Liu J, Qin L, Jing J, Yin T, et al. Switching between ticagrelor and clopidogrel in patients who underwent percutaneous coronary intervention: insight into contemporary practice in Chinese patients. Eur Heart J Suppl. 2016;18(suppl F):F19-26. DOI: https://doi.org/10.1093/eurheartj/suw034
Zettler ME, Peterson ED, McCoy LA, Effron MB, Anstrom KJ, Henry TD, et al. Switching of adenosine diphosphate receptor inhibitor after hospital discharge among myocardial infarction patients: insights from the TRANSLATE-ACS observational study. Am Heart J. 2017;183:62-8. DOI: https://doi.org/10.1016/j.ahj.2016.10.006
Bagai A, Peterson ED, Honeycutt E, Effron MB, Cohen DJ, Goodman SG, et al. In-hospital switching between adenosine diphosphate receptor inhibitors in patients with acute myocardial infarction treated with percutaneous coronary intervention: insights into contemporary practice from the TRANSLATE-ACS study. Eur Heart J Acute Cardiovasc Care. 2015;4(6):499-508. DOI: https://doi.org/10.1177/2048872614564082
Deharo P, Quilici J, Camoin-Jau L, Johnson TW, Bassez C, Bonnet G, et al. Benefit of switching dual antiplatelet therapy after acute coronary syndrome according to on-treatment platelet reactivity: the TOPIC-VASP pre-specified analysis of the TOPIC randomized study. JACC Cardiovasc Interv. 2017;10(24):2560-70. DOI: https://doi.org/10.1016/j.jcin.2017.08.044
Biscaglia S, Campo G, Pavasini R, Tebaldi M, Tumscitz C, Ferrari R. Occurrence, causes, and outcome after switching from ticagrelor to clopidogrel in a real-life scenario: data from a prospective registry. Platelets. 2016;27(5):484-7. DOI: https://doi.org/10.3109/09537104.2015.1119815
Franchi F, Rollini F. Switching from ticagrelor to clopidogrel: new answers and further questions. Thromb Haemost. 2017;117(2):207-8. DOI: https://doi.org/10.1160/TH16-12-0909
Turgeon RD, Koshman SL, Youngson E, Har B, Wilton SB, James MT, et al. Association of ticagrelor vs clopidogrel with major adverse coronary events in patients with acute coronary syndrome undergoing percutaneous coronary intervention. JAMA Intern Med. 2020;180(3):420-8. DOI: https://doi.org/10.1001/jamainternmed.2019.6447
Maqbool S, Ali MS, Rehman A, Ur Rehman ME, Iqbal J, Razzaq A, et al. Efficacy and safety profile of ticagrelor versus clopidogrel in percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS): a systematic review and meta-analysis. Cureus. 2023;15(10):e46455. DOI: https://doi.org/10.7759/cureus.46455
Winter MP, Koziński M, Kubica J, Aradi D, Siller-Matula JM. Personalized antiplatelet therapy with P2Y12 receptor inhibitors: benefits and pitfalls. Postepy Kardiol Interwencyjnej. 2015;11(4):259-80. DOI: https://doi.org/10.5114/pwki.2015.55596
Winter JL, Lindefjeld DS, Veas N, Guarda E, Valdebenito M, Méndez M, et al. Angiographic and electrocardiographic parameters of myocardial reperfusion in angioplasty of patients with ST elevation acute myocardial infarction loaded with ticagrelor or clopidogrel (MICAMI-TICLO trial). Cardiovasc Revasc Med. 2014;15(5):284-8. DOI: https://doi.org/10.1016/j.carrev.2014.07.001
Lun R, Dhaliwal S, Zitikyte G, Roy DC, Hutton B, Dowlatshahi D. Comparison of ticagrelor vs clopidogrel in addition to aspirin in patients with minor ischemic stroke and transient ischemic attack: a network meta-analysis. JAMA Neurol. 2022;79(2):141-8. DOI: https://doi.org/10.1001/jamaneurol.2021.4514
Dawson J, Merwick Á, Webb A, Dennis M, Ferrari J, Fonseca AC. European Stroke Organisation expedited recommendation for the use of short-term dual antiplatelet therapy early after minor stroke and high-risk TIA. Eur Stroke J. 2021;6(2):CLXXXVII-CXCI. DOI: https://doi.org/10.1177/23969873211000877
Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369(1):11-9. DOI: https://doi.org/10.1056/NEJMoa1215340
Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, et al. Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA. N Engl J Med. 2018;379(3):215-25. DOI: https://doi.org/10.1056/NEJMoa1800410
Johnston SC, Amarenco P, Denison H, Evans SR, Himmelmann A, James S, et al. Ticagrelor and aspirin or aspirin alone in acute ischemic stroke or TIA. N Engl J Med. 2020;383(3):207-17. DOI: https://doi.org/10.1056/NEJMoa1916870
Alfredsson J, Omar K, Csog J, Venetsanos D, Janzon M, Ekstedt M. Bleeding complications with clopidogrel or ticagrelor in ST-elevation myocardial infarction patients: a real life cohort study of two treatment strategies. Int J Cardiol Heart Vasc. 2020;27:100495. DOI: https://doi.org/10.1016/j.ijcha.2020.100495
Guan W, Lu H, Yang K. Choosing between ticagrelor and clopidogrel following percutaneous coronary intervention: a systematic review and meta-analysis (2007-2017). Medicine (Baltimore). 2018;97(43):e12978. DOI: https://doi.org/10.1097/MD.0000000000012978
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Copyright (c) 2026 Sandeep Bansal , L. Sreenivas Murthy , Hrudananda Mishra , B. C. Kalmath , Smit Srivastava , Rajeev Garg , Pravesh Vishwakarma , Aftab Khan , Baishali Nath
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