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Ticagrelor vs. Clopidogrel in Complex, Chronic Coronary Syndrome
Quick Takes
- “Complex PCI” (as it was defined in the study) was present in nearly one half of the cohort. Patients undergoing complex PCI had increased periprocedural MI (12.2% vs. 4.8%), angiographic complications (19.3% vs. 8.6%), death, MI, and stroke rates at 48 hours (12.7% vs 5.1) and 30 days (13.4% vs. 5.3%; p < 0.05) compared to noncomplex PCI patients.
- Ticagrelor use did not reduce the rate of periprocedural MI and major myocardial injuries when compared to clopidogrel among the complex PCI cohort. Bleeding risks were low and similar in both groups.
- Based on how complex patients were defined in this study, there does not appear to be a benefit of stronger platelet suppression with ticagrelor compared to clopidogrel among patients with complex stable CAD.
Study Questions:
What are outcomes of complex percutaneous coronary intervention (PCI) and the efficacy of ticagrelor versus clopidogrel in stable patients randomized in the ALPHEUS trial?
Methods:
“Complex PCI” was defined as at least one of the following criteria: stent length ≥60 mm, two-stent bifurcation, left main, bypass graft, chronic total occlusion, use of atherectomy or guiding catheter extensions, multiwire technique, and/or multiple stents. The primary endpoint was a composite of type 4a or b myocardial infarction (MI) and major myocardial injury during the 48 hours after PCI. Event rates were compared according to the presence or not of complex PCI criteria and based on interaction with ticagrelor or clopidogrel.
Results:
Among the 1,866 patients randomized, 910 (48.3%) PCIs were classified as complex PCI. The primary endpoint was more frequent in complex PCI (45.6% vs. 26.6%; p < 0.001) driven by higher rates of type 4 MI and angiographic complications (12.2% vs. 4.8%; p < 0.001 and 19.3% vs. 8.6%; p < 0.05, respectively). The composite of death, MI, and stroke at 48 hours (12.7% vs. 5.1 %; p < 0.05) and at 30 days (13.4% vs. 5.3%; p < 0.05) were more frequent in complex PCI. No interaction was found between PCI complexity and the randomized treatment for the primary endpoint (p for interaction = 0.47) nor the secondary endpoints.
Conclusions:
In chronic coronary syndrome, patients undergoing a complex PCI have higher rates of periprocedural and cardiovascular events, which are not reduced by ticagrelor as compared with clopidogrel.
Perspective:
The main ALPHEUS trial failed to demonstrate superiority of ticagrelor over clopidogrel to reduce periprocedural events in patients undergoing elective PCI. The current ancillary study evaluated a cohort of patients who underwent complex PCI in the ALPHEUS study. Complex PCI (as it was defined in the study) was present in nearly one half of the cohort. Patients undergoing complex PCI had increased periprocedural MI (12.2% vs. 4.8%), angiographic complications (19.3% vs. 8.6%), death, MI, and stroke rates at 48 hours (12.7% vs. 5.1) and 30 days (13.4% vs. 5.3%; p < 0.05) compared to noncomplex PCI patients. Ticagrelor use did not reduce the rate of periprocedural MI and major myocardial injuries when compared to clopidogrel among the ‘complex PCI’ cohort. Bleeding risks were low and similar in both groups. Based on how complex patients were defined in this study, there does not appear to be a benefit of stronger platelet suppression with ticagrelor compared to clopidogrel among patients with complex stable coronary artery disease (CAD).
Clinical Topics: Invasive Cardiovascular Angiography and Intervention
Keywords: Clopidogrel, Percutaneous Coronary Intervention, Ticagrelor
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