Ticagrelor vs Clopidogrel in ACS patients undergoing PCI in routine clinical practice

Main Takeaway

• Risk for net adverse clinical events (NACE) was not significantly different between ticagrelor at 12 months compared with clopidogrel
• Study population: 62,580 patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI) in routine clinical practice
• Ticagrelor was associated with higher risks for haemorrhagic events and dyspnoea vs clopidogrel

Why This Matters

• Recent observational studies question whether ticagrelor vs clopidogrel is associated with better outcomes in routine clinical practice
• Current guidelines: recommend ticagrelor with aspirin in preference to clopidogrel in patients with ACS

Study Design

Retrospective cohort study: 183,579 patients (age range, 30-89 years) with ACS who underwent PCI and received ticagrelor or clopidogrel

Patients were matched using propensity score:

• Ticagrelor (n=31,290)
• Clopidogrel (n=31,290)

Primary endpoint: NACE at 12 months

• Ischaemic events
  [recurrent acute myocardial infarction, revascularisation or ischaemic stroke]
• Haemorrhagic events
  [haemorrhagic stroke or gastrointestinal bleeding]

Secondary outcomes: NACE or mortality, all-cause mortality, composite ischaemic events, composite haemorrhagic events, individual components of the primary outcome, dyspnoea at 12 months

Key Results

95.5% of matched patients used aspirin with ticagrelor or clopidogrel among the 31,290 propensity-matched pairs

The risk for NACE was not significantly different between ticagrelor and clopidogrel groups (HR, 1.05; 95% CI, 1.00-1.10; P=0.06)

• No significant difference was found between the 2 groups for:
  • NACE or mortality (HR, 1.03; 95% CI, 0.98-1.08; P=0.21)
  • Ischaemic events (HR, 1.03; 95% CI, 0.98-1.08; P=0.32)
  • All-cause mortality (HR, 0.97; 95% CI, 0.81-1.16; P=0.74)
• Ticagrelor vs clopidogrel group showed a significantly higher risk for:
  • Haemorrhagic events (HR, 1.35; 95% CI, 1.13-1.61; P=0.001)
  • Dyspnoea (HR, 1.21; 95% CI, 1.17-1.26; P<0.001)

Limitations

• The study did not include information on aspirin dosage, angiographic findings, or PCI procedure
• The burden of overall bleeding events could have been underestimated or overestimated
• Neither the proportion of patients who switched antiplatelet drugs nor its effects were quantified
• The effect of pre-treatment with an antiplatelet agent was not assessed
• The mortality rate might have been underestimated
• Patients who used prasugrel for dual antiplatelet therapy were not included