Ticagrelor and Clopidogrel in Elderly ACS Patients: SWEDEHEART Registry

Quick Takes

  • Ticagrelor use in patients ≥80 years of age is associated with excess risk of death and bleeding compared to clopidogrel.
  • Among patients <80 years old, ticagrelor is associated with lower rates of death, myocardial infarction, and stroke, but excess risk of bleeding compared to clopidogrel.
  • Findings from this observational study highlight a need for a randomized controlled trial comparing P2Y12 inhibitor use in the elderly.

Study Questions:

What is the efficacy and safety of ticagrelor versus clopidogrel in older patients presenting with acute coronary syndrome?

Methods:

This was an observational analysis of all patients ≥80 years (n = 14,005) who were discharged alive with aspirin combined with either clopidogrel (60.2%) or ticagrelor (39.8%) after a myocardial infarction (MI) between 2010 and 2017 registered in the national registry SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies). Inverse probability treatment weighting was used in Cox regression models to adjust for differences in demographics, in-hospital therapies, and medications. The primary ischemic outcome (death, MI, or stroke) and bleeding were obtained from national registries at 1 year. A sensitivity analysis in patients <80 years old was performed.

Results:

In patients ≥80 years, the incidence of the primary ischemic outcome (hazard ratio, 0.97 [95% confidence interval, 0.88-1.06]) was similar for ticagrelor- and clopidogrel-treated patients. Ticagrelor was associated with a 17% and 48% higher risk of death (1.17 [1.03-1.32]) and bleeding (1.48 [1.25-1.76]), but a lower risk of MI (0.80 [0.70-0.92]) and stroke (0.72 [0.56-0.93]). In patients <80 years old, incidence of the primary ischemic outcome was 17% (0.83 [0.77-0.89]) lower with ticagrelor. Ticagrelor was associated with a 15% (0.85 [0.76-0.96]) lower risk of death, 32% higher risk of bleeding (1.32 [1.18-1.47]), but lower risk of MI (0.82 [0.75-0.91]) and stroke (0.82 [0.69-0.98]).

Conclusions:

Ticagrelor use among elderly MI patients was associated with a higher risk of bleeding and death compared with clopidogrel. A randomized study of ticagrelor versus clopidogrel in the elderly is needed.

Perspective:

Barring the limitations of this well-done observational study, there appears to be differential safety and efficacy of ticagrelor and clopidogrel based on age. Findings from this analysis suggest that ticagrelor use in the elderly comes with excess risk of death and bleeding compared to clopidogrel. This is countered by an improved ischemic endpoint such as MI and stroke in favor of clopidogrel among the older patients. Among patients <80 years, ticagrelor use was associated with lower rates of death, MI, and stroke, but a significantly higher risk of bleeding. These findings might point to the importance of bleeding and its link with mortality in older patients. The authors call for a randomized controlled trial comparing the two P2Y12 inhibitors based on their results.

Keywords: ESC Congress, ESC20, Acute Coronary Syndrome, Aspirin, Geriatrics, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Patient Discharge, Platelet Aggregation Inhibitors, Primary Prevention, Purinergic P2Y Receptor Antagonists, Registries, Risk, Stroke


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