Outcomes With Ticagrelor or Clopidogrel After Acute MI

Study Questions:

What are the clinical outcomes with ticagrelor or clopidogrel after acute myocardial infarction (AMI) in a large real-world population post-acute coronary syndrome (ACS)?

Methods:

The investigators performed a prospective cohort study in 45,073 ACS patients enrolled into the SWEDEHEART (Swedish Web system for Enhancement and Development of Evidence-based care in Heart Disease Evaluated According to Recommended Therapies) registry who were discharged on ticagrelor (n = 11,954) or clopidogrel (n = 33,119) between January 1, 2010 and December 31, 2013. The primary outcome was a composite of all-cause death, re-admission with myocardial infarction (MI) or stroke, secondary outcomes as the individual components of the primary outcome, and re-admission with bleeding.

Results:

The risk of the primary outcome with ticagrelor vs. clopidogrel was 11.7 vs. 22.3% (adjusted hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.78-0.93), risk of death 5.8 vs. 12.9% (adjusted HR, 0.83; 95% CI, 0.75-0.92), and risk of MI 6.1 vs. 10.8% (adjusted HR, 0.89; 95% CI, 0.78-1.01) at 24 months. Re-admission with bleeding with ticagrelor vs. clopidogrel occurred in 5.5 vs. 5.2% (adjusted HR, 1.20; 95% CI, 1.04–1.40). In a subset of patients undergoing percutaneous coronary intervention (PCI) on ticagrelor vs. clopidogrel, the PCI-related in-hospital bleeding was 3.7 vs. 2.7% (adjusted odds ratio, 1.57; 95% CI, 1.30-1.90).

Conclusions:

The authors concluded that ticagrelor was associated with a lower risk of death, MI, or stroke, as well as death alone, but with higher risk of bleeding as compared to clopidogrel.

Perspective:

This study reports that real-world outcomes in patients with ACS treated with ticagrelor vs. clopidogrel appeared similar to the benefit achieved in the PLATO trial. Patients discharged on ticagrelor had lower incidence of the composite of death, MI, or stroke, as well as lower mortality alone. However, those prescribed ticagrelor were also at higher risk of bleeding, as evidenced both by more re-admissions with bleeding and more PCI-related in-hospital bleeding events. Ticagrelor appears to be the preferred drug for patients with ACS except in those at high risk of bleeding.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Prevention, Interventions and ACS

Keywords: Acute Coronary Syndrome, Adenosine, Hemorrhage, Mortality, Myocardial Infarction, Patient Readmission, Percutaneous Coronary Intervention, Primary Prevention, Purinergic P2Y Receptor Antagonists, Risk, Stroke, Treatment Outcome


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