Predictors of P2Y12 Inhibitor Selection in Patients with Acute Coronary Syndrome: The Role of Age and Baseline aPTT Values
DOI:
https://doi.org/10.35451/69snqx87Keywords:
Acute Coronary Syndrome, Dual Antiplatelet Therapy, P2Y12 Inhibitors, Ticagrelor, aPTT, ClopidogrelAbstract
Background: Although international guidelines strongly recommend potent P2Y12 inhibitors (ticagrelor) for acute coronary syndrome (ACS) patients, real-world clinical adherence frequently deviates, creating a distinct evidence-practice gap, particularly in developing nations. Aim: This retrospective cross-sectional study aimed to evaluate sociodemographic and laboratory predictors influencing the selection of dual antiplatelet therapy (clopidogrel versus ticagrelor) among 254 ACS patients at a tertiary hospital in Jakarta from January to December 2025. Methode: Data were extracted from medical records and analyzed using multivariate binary logistic regression. Result: The results demonstrated that the vast majority of the cohort (83.8%, n=213) received an aspirin-clopidogrel combination, whereas only 16.1% (n=41) were initiated on ticagrelor. Multivariate analysis identified age and baseline activated partial thromboplastin time (aPTT) as significant independent predictors of therapy selection, specifically revealing that advancing age (aOR 0.946; 95% CI: 0.910–0.983; p=0.005) and prolonged baseline aPTT (aOR 0.854; 95% CI: 0.763–0.992; p=0.039) substantially reduced the probability of ticagrelor prescription. These findings establish that advanced age and prolonged baseline aPTT operate as independent determinants driving clinicians to de-escalate P2Y12 therapy to clopidogrel. Conclusion: This highlights the application of a heuristic approach in real-world clinical practice, where mitigating bleeding risk in vulnerable demographics is systematically prioritized over maximizing the efficacy of potent anti-ischemic agents.
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[1] Chong, B., Jayabaskaran, J., Jauhari, S. M., Chan, S. P., Goh, R., Kueh, M. T. W., Li, H., Chin, Y. H., Kong, G., Anand, V. V., Wang, J.-W., Muthiah, M., Jain, V., Mehta, A., Lim, S. L., Foo, R., Figtree, G. A., Nicholls, S. J., Mamas, M. A., … Chan, M. Y. (2025). Global burden of cardiovascular diseases: projections from 2025 to 2050. European Journal of Preventive Cardiology, 32(11), 1001–1015. https://doi.org/10.1093/eurjpc/zwae281
[2] Stark, B. A., DeCleene, N. K., Desai, E. C., Hsu, J. M., Johnson, C. O., Lara-Castor, L., LeGrand, K. E., A, P. B., Aalipour, M. A., Aalruz, H., Abafita, B. J., Abaraogu, U. O., Abavisani, M., Abbas, N., Abbasi, M., Abbasian, M., Abbastabar, H., Abd Al Magied, A. H. A., ElHafeez, S. A., … Roth, G. A. (2025). Global, Regional, and National Burden of Cardiovascular Diseases and Risk Factors in 204 Countries and Territories, 1990-2023. JACC, 86(22), 2167–2243. https://doi.org/10.1016/j.jacc.2025.08.015
[3] Wang, Y., Li, J., Bilal, H., Yu, X., & Sun, L. (2025). The Rising Tide of Coronary Crisis: Decoding Age‐Specific Disparities in Ischemic Heart Disease Burden Through the Global Burden of Disease Study 2021 Revelations: An Ecological Study. Health Science Reports, 8(10). https://doi.org/10.1002/hsr2.71244
[4] Hao, K., Taniguchi, T., Kojima, S., Arai, M., Aoyama, R., Tateishi, K., Minami, Y., Yokose, M., Tanaka, A., Matsuo, K., Yamaguchi, J., Mano, T., Yamamoto, T., Nakayama, N., Hanada, H., Hashiba, K., Nakashima, T., Kondo, T., Noguchi, T., … Kikuchi, M. (2025). Early Invasive Strategy in Non-ST-Elevation Acute Coronary Syndrome With Congestive Heart Failure ― A Systematic Review and Meta-Analysis ―. Circulation Reports, 7(9), CR-25-0104. https://doi.org/10.1253/circrep.CR-25-0104
[5] Mills, G. B., Kotanidis, C. P., Mehta, S., Tiong, D., Badings, E. A., Engstrøm, T., Van ’T Hof, A. W. J., Høfsten, D., Holmvang, L., Jobs, A., Køber, L., Milasinovic, D., Milosevic, A., Stankovic, G., Thiele, H., Mehran, R., & Kunadian, V. (2025). Early Versus Delayed Invasive Management of Female Patients with Non-ST-Elevation Acute Coronary Syndrome: An Individual Patient Data Meta-Analysis. Circulation: Cardiovascular Interventions, 18(3), e014763. https://doi.org/10.1161/CIRCINTERVENTIONS.124.014763
[6] Hwang, D., Lim, H.-S., Park, K. W., Shin, W.-Y., Kang, J., Han, J.-K., Yang, H.-M., Kang, H.-J., Koo, B.-K., Cho, Y.-K., Hong, S. J., Kim, S., Jo, S.-H., Kim, Y. H., Kim, W., Lee, S. Y., Oh, S. K., Kim, D.-B., & Kim, H.-S. (2022). Durable polymer versus biodegradable polymer drug-eluting stents in patients with acute coronary syndrome undergoing complex percutaneous coronary intervention: a post hoc analysis of the HOST-REDUCE-POLYTECH-ACS trial. EuroIntervention, 18(11), e910–e919. https://doi.org/10.4244/EIJ-D-22-00372
[7] Kim, H.-S., Kang, J., Hwang, D., Han, J.-K., Yang, H.-M., Kang, H.-J., Koo, B.-K., Rhew, J. Y., Chun, K.-J., Lim, Y.-H., Bong, J. M., Bae, J.-W., Lee, B. K., & Park, K. W. (2020). Prasugrel-based de-escalation of dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome (HOST-REDUCE-POLYTECH-ACS): an open-label, multicentre, non-inferiority randomised trial. The Lancet, 396(10257), 1079–1089. https://doi.org/10.1016/S0140-6736(20)31791-8
[8] Kim, C. J., Park, M.-W., Kim, M. C., Choo, E.-H., Hwang, B.-H., Lee, K. Y., Choi, Y. S., Kim, H.-Y., Yoo, K.-D., Jeon, D.-S., Shin, E.-S., Jeong, Y.-H., Seung, K.-B., Jeong, M. H., Yim, H. W., Ahn, Y., Chang, K., Kim, C. J., Park, M.-W., … Sung, K.-C. (2021). Unguided de-escalation from ticagrelor to clopidogrel in stabilised patients with acute myocardial infarction undergoing percutaneous coronary intervention (TALOS-AMI): an investigator-initiated, open-label, multicentre, non-inferiority, randomised trial. The Lancet, 398(10308), 1305–1316. https://doi.org/10.1016/S0140-6736(21)01445-8
[9] Byrne, R. A., Rossello, X., Coughlan, J. J., Barbato, E., Berry, C., Chieffo, A., Claeys, M. J., Dan, G.-A., Dweck, M. R., Galbraith, M., Gilard, M., Hinterbuchner, L., Jankowska, E. A., Jüni, P., Kimura, T., Kunadian, V., Leosdottir, M., Lorusso, R., Pedretti, R. F. E., … Group, E. S. C. S. D. (2023). 2023 ESC Guidelines for the management of acute coronary syndromes: Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology (ESC). European Heart Journal, 44(38), 3720–3826. https://doi.org/10.1093/eurheartj/ehad191
[10] Rao, S. V., O’Donoghue, M. L., Ruel, M., Rab, T., Tamis-Holland, J. E., Alexander, J. H., Baber, U., Baker, H., Cohen, M. G., Cruz-Ruiz, M., Davis, L. L., de Lemos, J. A., DeWald, T. A., Elgendy, I. Y., Feldman, D. N., Goyal, A., Isiadinso, I., Menon, V., Morrow, D. A., … Hundley, J. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. In Circulation (Vol. 151, Number 13, pp. e771–e862). Lippincott Williams and Wilkins. https://doi.org/10.1161/CIR.0000000000001309
[11] Sun, M., Cui, W., & Li, L. (2022). Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in Acute Coronary Syndrome: A Comprehensive Meta-Analysis. Frontiers in Cardiovascular Medicine, 8. https://doi.org/10.3389/fcvm.2021.818215
[12] At Thobari, J., Krisdinarti, L., Nugroho, D., Haposan, J., Firdaus, I., Suryandani, Rr. A. R., Munawar, M., & Agung, J. (2022). Cost-Effectiveness of Ticagrelor for Acute Coronary Disease to Prevent Cardiovascular Events in Three Hospitals in Indonesia. Open Access Macedonian Journal of Medical Sciences, 10(A), 1211–1217. https://doi.org/10.3889/oamjms.2022.9671
[13] Nafrialdi, N., Handini, N. M., Instiaty, I., & Wijaya, I. P. (2018). A cost-effectiveness and safety analysis of dual antiplatelet therapy comparing aspirin–clopidogrel to aspirin–ticagrelor in patients with acute coronary syndrome. Medical Journal of Indonesia, 27(4), 262–270. https://doi.org/10.13181/mji.v27i4.3024
[14] Choo, E. H., Choi, I. J., Lim, S., Moon, D., Kim, C. J., Park, M. W., Kim, M. C., Hwang, B. H., Lee, K. Y., Seok Choi, Y., Kim, H. Y., Yoo, K. D., Jeon, D. S., Ahn, Y., & Chang, K. (2022). Prognosis and the Effect of De-Escalation of Antiplatelet Therapy after Nuisance Bleeding in Patients with Myocardial Infarction. Circulation: Cardiovascular Interventions, 15(12), E012157. https://doi.org/10.1161/CIRCINTERVENTIONS.122.012157
[15] Kristin, E., Kris Dinarti, L., Yasmina, A., Pratiwi, W. R., Pinzon, R. T., & Indra Jaya, S. (2022). Persistence with Antiplatelet and Risk of Major Adverse Cardiac and Cerebrovascular Events in Acute Coronary Syndrome Patients after Percutaneous Coronary Intervention in Indonesia: A Retrospective Cohort Study. Open Access Macedonian Journal of Medical Sciences, 10(B), 900–904. https://doi.org/10.3889/oamjms.2022.9180
[16] Kite, T. A., Kurmani, S. A., Bountziouka, V., Cooper, N. J., Lock, S. T., Gale, C. P., Flather, M., Curzen, N., Banning, A. P., McCann, G. P., & Ladwiniec, A. (2022). Timing of invasive strategy in non-ST-elevation acute coronary syndrome: a meta-analysis of randomized controlled trials. European Heart Journal, 43(33), 3148–3161. https://doi.org/10.1093/eurheartj/ehac213
[17] Kim, C. J., Park, M.-W., Kim, M. C., Choo, E.-H., Hwang, B.-H., Lee, K. Y., Choi, Y. S., Kim, H.-Y., Yoo, K.-D., Jeon, D.-S., Shin, E.-S., Jeong, Y.-H., Seung, K.-B., Jeong, M. H., Yim, H. W., Ahn, Y., Chang, K., Kim, C. J., Park, M.-W., … Sung, K.-C. (2021). Unguided de-escalation from ticagrelor to clopidogrel in stabilised patients with acute myocardial infarction undergoing percutaneous coronary intervention (TALOS-AMI): an investigator-initiated, open-label, multicentre, non-inferiority, randomised trial. The Lancet, 398(10308), 1305–1316. https://doi.org/10.1016/S0140-6736(21)01445-8
[18] Sibbing, D., Aradi, D., Jacobshagen, C., Gross, L., Trenk, D., Geisler, T., Orban, M., Hadamitzky, M., Merkely, B., Kiss, R. G., Komócsi, A., Dézsi, C. A., Holdt, L., Felix, S. B., Parma, R., Klopotowski, M., Schwinger, R. H. G., Rieber, J., Huber, K., … Rasp, O. (2017). Guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention (TROPICAL-ACS): a randomised, open-label, multicentre trial. The Lancet, 390(10104), 1747–1757. https://doi.org/10.1016/S0140-6736(17)32155-4
[19] Meng, S., Guo, L., Ye, Z., Wang, J., Ding, H., Wu, S., & Huang, R. (2022). Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in Elderly Patients Undergoing Percutaneous Coronary Intervention: A Cohort Study. Clinical Interventions in Aging, Volume 17, 331–341. https://doi.org/10.2147/CIA.S355210
[20] Kosowski, M., Kocjan, M., Mazurkiewicz, M., Gamrot-Wrzoł, M., Ryl, S., Nowakowski, K., Kawecki, J., Kukulski, T., Kawecki, D., & Morawiec-Migas, B. (2025). Bleeding Complications of Anticoagulation Therapy Used in the Treatment of Acute Coronary Syndromes—Review of the Literature. Journal of Clinical Medicine, 14(10), 3391. https://doi.org/10.3390/jcm14103391
[21] Szummer, K., Hofmann, R., & Jernberg, T. (2021). Use of DAPT in ACS in the Elderly. https://www.acc.org/latest-in-cardiology/articles/2021/07/08/12/50/use-of-dapt-in-acs-in-the-elderly
[22] Beck, P. J., Benfield, J., & Morales, J. (2023). Friend or Foe: Factor XII Deficiency Discovered Incidentally during Management of NSTEMI. Case Reports in Hematology, 2023, 1–4. https://doi.org/10.1155/2023/5926340
[23] Faizur Rahman, M. E., Wedagedera, V., Parker, W. A. E., & Storey, R. F. (2025). Pharmacotherapeutic options for coronary thrombosis treatment: where are we today? Expert Opinion on Pharmacotherapy, 26(2), 187–202. https://doi.org/10.1080/14656566.2025.2450353
[24] Kini, V., Breathett, K., Groeneveld, P. W., Ho, P. M., Nallamothu, B. K., Peterson, P. N., Rush, P., Wang, T. Y., Zeitler, E. P., & Borden, W. B. (2022). Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association. Circulation: Cardiovascular Quality and Outcomes, 15(3), E000105. https://doi.org/10.1161/HCQ.0000000000000105
[25] Baiardi, G., Calvini, G., Panarello, S., Fioravanti, C., Stella, M., Martelli, A., Antonucci, G., & Mattioli, F. (2023). Prescriptive Appropriateness: Inhospital Adherence to Proton Pump Inhibitors Deprescription Flow Chart. Pharmaceuticals, 16(5), 635. https://doi.org/10.3390/ph16050635
[26] Falster, M. O., Schaffer, A. L., Wilson, A., Nasis, A., Jorm, L. R., Hay, M., Leeb, K., Pearson, S., & Brieger, D. (2022). Evidence-practice gaps in P2Y12 inhibitor use after hospitalisation for acute myocardial infarction: findings from a new population-level data linkage in Australia. Internal Medicine Journal, 52(2), 249–258. https://doi.org/10.1111/imj.15036
[27] Wang, Z., Ma, R., Li, X., Li, X., Xu, Q., Yao, Y., Wang, C., & Lv, Q. (2024). Clinical efficacy of clopidogrel and ticagrelor in patients undergoing off-pump coronary artery bypass grafting: a retrospective cohort study. International Journal of Surgery (London, England), 110(6), 3450–3460. https://doi.org/10.1097/JS9.0000000000001246
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