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Research Article | Open Access

Dual antiplatelets therapy prescription trends and mortality outcomes among senior citizens with acute coronary syndrome: insights from the Malaysian National Cardiovascular Disease Database

Siti Zaleha Suki1,2,*(), Ahmad Syadi Mahmood Zuhdi3,*, Abqariyah Yahya4,*, Nur Lisa Zaharan1,*()
Department of Pharmacology, Universiti Malaya, Kuala Lumpur, Malaysia
Centre of Preclinical Science Studies (Pharmacology), Faculty of Dentistry, Universiti Teknologi MARA, Selangor, Malaysia
Cardiology Unit, Department of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
Department of Social and Preventive Medicine, Universiti Malaya, Kuala Lumpur, Malaysia

*The authors contributed equally to this manuscript

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Abstract

OBJECTIVES

To examine 5-year trends and variations in dual antiplatelet therapy (DAPT) prescription among multiethnic Malaysian patients aged 60 years and older.

METHODS

Using the Malaysian National Cardiovascular Disease-Acute Coronary Syndrome (NCVD-ACS) registry, DAPT 5-year temporal trends prescribing patterns at discharge were examined. Multivariate logistic regression was used to calculate the adjusted odds ratio (aOR) of DAPT prescription. The 1-year all-cause mortality by Cox proportional hazard regression model (adjusted hazard ratio, aHR) using inverse proportional weighting covariates adjustment was performed to assess DAPT prognostic impacts.

RESULTS

Data of patients aged 60 years and older were extracted from 2013 to 2017 (n = 3718, mean age: 68 ± 6.74 years, men: 72%, and Malay ethnicity: 43%). The majority of patients were diagnosed with non-ST-segment elevation acute coronary syndrome (63%), predisposed hypertension (76%) and were overweight (74%), while only 35% of patients underwent percutaneous coronary intervention. Over the five years, there was a significant increasing trend in DAPT prescriptions (P < 0.001), with the aspirin-clopidogrel combination being the most common. Aspirin-ticagrelor prescriptions have also increased over the years. Variations in DAPT prescriptions were observed based on patient characteristics. Patients who underwent percutaneous coronary intervention were more likely to be prescribed DAPT in general (aOR = 2.53, 95% CI: 1.95–3.28, P < 0.001) and aspirin-ticagrelor specifically (aOR = 7.76, 95% CI: 5.65–10.68, P < 0.001). Patients with chronic lung disease (aOR = 0.62, 95% CI: 0.42–0.92, P = 0.02) and a history of angina within two weeks (aOR = 0.69, 95% CI: 0.56–0.85, P < 0.001) were approximately 30% less likely to be prescribed DAPT. Approximately 15% of 1-year all-cause mortality were reported. Older patients prescribed DAPT showed significantly higher survival rates than those who were not (aHR < 1.0, P < 0.001). Aspirin-ticagrelor was associated with higher survival rates than aspirin-clopidogrel (aHR = 0.21, 95% CI: 0.11–0.40, P < 0.001).

CONCLUSIONS

Despite the optimal prescription rate and variation of DAPT in the older Malaysian population, there is room for investigation and improvement in the prescription of newer DAPT combinations that have been suggested to improve patient survival.

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Journal of Geriatric Cardiology
Volume 22 Issue 2,
February 2025
Pages 237-245
DOI: 10.26599/1671-5411.2025.02.004
Cite this article:
Suki SZ, Zuhdi ASM, Yahya A, et al. Dual antiplatelets therapy prescription trends and mortality outcomes among senior citizens with acute coronary syndrome: insights from the Malaysian National Cardiovascular Disease Database. Journal of Geriatric Cardiology, 2025, 22(2): 237-245. https://doi.org/10.26599/1671-5411.2025.02.004
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Demographic and clinical characteristics of patients prescribed with DAPT, AC and AT on day of discharge from 2013 to 2017.

Demographic/Clinical characteristicsOverall (n = 3718)DAPT (n = 3222, 87%)AC (n = 2828, 77%)AT (n = 316, 9%)
Data are presented as %. AC: aspirin-clopidogrel; AT: aspirin-ticagrelor; DAPT: dual antiplatelet therapy.
Gender
Men71.95%88.04%77.68%9.27%
Women28.05%83.13%75.26%7.00%
Age, yrs
60-6434.64%89.75%77.87%10.71%
65-6927.25%86.77%76.51%9.38%
70-7418.07%83.78%75.30%8.04%
75-7912.26%85.09%78.29%5.04%
≥ 807.77%81.66%76.82%3.81%
Ethnic group
Malay43.36%88.46%78.66%9.31%
Chinese25.49%84.26%76.04%6.40%
Indian21.41%89.70%75.88%12.44%
Other Malaysians8.74%77.54%74.46%2.77%
Acute coronary syndrome stratum
ST-segment elevation myocardial infarction37.25%91.41%73.29%17.33%
Non-ST-segment elevation acute coronary syndrome62.75%83.84%79.21%3.47%
Intervention
Percutaneous coronary intervention35.10%93.26%71.80%20.46%
Coronary artery bypass grafting1.66%77.05%75.41%1.64%
Risk factors
Hypertension75.69%85.61%76.87%7.78%
Diabetes mellitus51.10%85.68%75.26%9.27%
Dyslipidaemia44.94%85.64%7.08%7.36%
Tobacco smoking45.35%89.50%79.42%9.02%
Family history32.71%83.96%74.84%7.65%
Other factors
Body mass index > 23.0 kg/m273.64%86.92%76.30%9.46%
Congestive heart failure7.10%81.44%75.76%3.79%
Chronic kidney disease10.19%82.85%77.84%3.69%
Chronic lung disease4.92%78.14%73.77%3.83%
Cerebrovascular disease4.95%84.24%75.54%8.15%
Peripheral vascular disease0.59%86.36%81.82%–
Cardiogenic shock4.90%86.81%73.08%12.64%
Angina within 2 weeks61.92%85.49%75.02%9.47%

Variations in DAPT, AC, and AT prescriptions on the day of hospital discharge for Malaysian elderly with acute coronary syndrome.

Demographic/Clinical characteristicsDAPTACAT
aOR (95% CI)P-valueaOR (95% CI)P-valueaOR (95% CI)P-value
AC: aspirin-clopidogrel; AT: aspirin-ticagrelor; DAPT: dual antiplatelet therapy.
Gender
Men (reference)
Women0.85 (0.67–1.08)0.190.94 (0.77–1.15)0.560.90 (0.64–1.26)0.54
Age
60-64 (reference)
65-690.79 (0.61–1.03)0.080.91 (0.75–1.11)0.360.97 (0.72–1.32)0.86
70-740.67 (0.50–0.89)0.010.83 (0.66–1.04)0.0960.99 (0.69–1.43)0.97
75-790.82 (0.59–1.14)0.240.97 (0.75–1.27)0.850.66 (0.41–1.09)0.11
≥ 800.711 (0.49–1.03)0.070.87 (0.63–1.20)0.400.75 (0.38–1.49)0.41
Ethnic group
Malay (reference)
Chinese0.76 (0.60–0.97)0.030.83 (0.68–1.01)0.060.80 (0.57–1.12)0.19
Indian1.27 (0.95–1.70)0.100.94 (0.76–1.15)0.531.42 (1.04–1.92)0.03
Other Malaysians0.45 (0.33–0.62)< 0.0010.73 (0.55–0.97)0.030.33 (0.16–0.67)0.002
Acute coronary syndrome stratum
ST-segment elevation myocardial infarction (reference)
Non-ST-segment elevation acute coronary syndrome0.81 (0.63–1.05)0.121.45 (1.20–1.74)< 0.0010.31 (0.23–0.42)< 0.001
Intervention
Percutaneous coronary intervention2.53 (1.95–3.28)< 0.0010.71 (0.60–0.84)< 0.0017.76 (5.65–10.68)< 0.001
Risk factors
Hypertension0.87 (0.67–1.14)0.331.06 (0.87–1.29)0.570.82 (0.61–1.11)0.20
Diabetes mellitus0.85 (0.68–1.05)0.120.84 (0.71–0.99)0.041.16 (0.89–1.53)0.27
Dyslipidaemia1.03 (0.84–1.26)0.791.02 (0.87–1.21)0.760.95 (0.73–1.24)0.70
Tobacco smoking1.41 (1.11–1.78)0.011.32 (1.10–1.59)0.0030.85 (0.63–1.14)0.27
Family history0.79 (0.64–0.97)0.030.74 (0.62–0.88)0.0011.50 (1.10–2.03)0.01
Other factors
Body mass index > 23.0 kg/m21.03 (0.83–1.29)0.790.84 (0.70–1.01)0.061.44 (1.05–1.97)0.02
Congestive heart failure0.91 (0.64–1.28)0.580.91 (0.67–1.24)0.560.84 (0.42–1.69)0.62
Chronic kidney disease0.99 (0.73–1.35)0.951.04 (0.80–1.37)0.760.70 (0.38–1.26)0.23
Chronic lung disease0.62 (0.42–0.92)0.020.69 (0.48–0.97)0.040.78 (0.34–1.78)0.55
Cerebrovascular disease0.86 (0.56–1.31)0.480.88 (0.62–1.25)0.471.18 (0.65–2.16)0.59
Peripheral vascular disease1.09 (0.31–3.84)0.891.36 (0.45–4.15)0.59–1.00
Cardiogenic shock0.68 (0.43–1.09)0.110.91 (0.64–1.29)0.600.81 (0.49–1.32)0.39
Angina within 2 weeks0.69 (0.56–0.85)< 0.0010.74 (0.63–0.88)< 0.0011.00 (0.76–1.31)0.99