Ticagrelor in Patients With ST-Elevation Myocardial Infarction Treated With Pharmacological Thrombolysis - TREAT

Contribution To Literature:

The TREAT trial showed that delayed administration of ticagrelor after fibrinolysis for STEMI was noninferior to clopidogrel for major bleeding.

Description:

The goal of the trial was to evaluate ticagrelor compared with clopidogrel among patients who received fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI).

Study Design

  • Randomized
  • Parallel
  • Stratified

Patients who received fibrinolytic therapy for STEMI were randomized to delayed ticagrelor (n = 1,913) versus clopidogrel (n = 1,886). Patients were randomized a median of 11 hours after fibrinolysis and 90% had been pretreated with clopidogrel.

  • Total number of enrollees: 3,799
  • Duration of follow-up: 30 days
  • Mean patient age: 58 years
  • Percentage female: 23%
  • Percentage with diabetes: 17%

Inclusion criteria:

  • Age <75 years
  • Received fibrinolytic therapy for STEMI
  • Presentation within 24 hours from symptom onset

Exclusion criteria:

  • Contraindication to clopidogrel
  • Use of oral anticoagulation
  • Increased risk of bradycardia
  • Concomitant therapy with a strong cytochrome P-450 3A inhibitor or inducer

Principal Findings:

The primary outcome of TIMI major bleeding occurred in 0.73% of the ticagrelor group vs. 0.69% of the clopidogrel group (p < 0.001 for noninferiority).

Secondary outcomes:

  • Fatal bleeding: 0.16% with ticagrelor vs. 0.11% with clopidogrel (p = 0.67)
  • Intracranial bleeding: 0.42% with ticagrelor vs. 0.37% with clopidogrel (p = 0.82)
  • Major adverse cardiovascular events: 4.0% with ticagrelor vs. 4.3% with clopidogrel (p = 0.57)

Interpretation:

Among patients <75 years of age who were treated with fibrinolysis for STEMI, delayed administration of ticagrelor was noninferior to clopidogrel. There was no excess of major bleeding, fatal bleeding, or intracranial bleeding with ticagrelor vs. clopidogrel. Although the trial was not powered for efficacy, there was no apparent ischemic benefit with ticagrelor. Ticagrelor represents a treatment option in such patients (i.e., clopidogrel allergy); however, unless future trials show otherwise, ticagrelor is not preferential to clopidogrel after fibrinolysis for STEMI.

References:

The Writing Committee for the TREAT Study Group. Ticagrelor vs Clopidogrel After Fibrinolytic Therapy in Patients With ST-Elevation Myocardial Infarction: A Randomized Clinical Trial. JAMA Cardiol 2018;Mar 11:[Epub ahead of print].

Editor’s Note: Yancy CW, Harrington RA. The TREAT Trial—Moving ST-Elevation Myocardial Infarction: Care Forward, With More to Do. JAMA Cardiol 2018;Mar 11:[Epub ahead of print].

Presented by Dr. Otavio Berwanger at the American College of Cardiology Annual Scientific Session (ACC 2018), Orlando, FL, March 11, 2018.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Prevention, Anticoagulation Management and ACS

Keywords: ACC18, ACC Annual Scientific Session, Acute Coronary Syndrome, Adenosine, Anticoagulants, Fibrinolysis, Hemorrhage, Intracranial Hemorrhages, Myocardial Infarction, Secondary Prevention, Thrombolytic Therapy


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