Ticagrelor vs. Clopidogrel After PCI for ACS

Study Questions:

Is there a difference in major adverse cardiac events (MACE), bleeding, side effects, and adherence among patients taking outpatient ticagrelor compared to clopidogrel after undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS)?


This was a population-based retrospective cohort study from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry. Patients who were discharged alive after PCI for ACS from April 2012 to March 2016 with 1-year follow-up were analyzed. MACE was defined as a composite of all-cause death, hospitalization for ACS, unplanned coronary revascularization, or stent thrombosis within 365 days after index PCI. Secondary outcomes included hospitalization for major bleeding and emergency department visit for dyspnea.


The patient population consisted of 11,185 individuals who underwent PCI (median [interquartile range] age, 61 [54-71] years). The minority of patients were women (n = 2,760 [24.7%]). Ticagrelor users (4,076 [36.4%]) were generally younger and had fewer cardiac and noncardiac comorbidities than clopidogrel users. Ticagrelor was not associated with a lower risk of MACE (adjusted hazard ratio [aHR], 0.97; 95% confidence interval [CI], 0.85-1.10); however, it was associated with an increased risk of major bleeding (aHR, 1.51; 95% CI, 1.29-1.78) and dyspnea (aHR, 1.98; 95% CI, 1.47-2.65). A total of 3,328 ticagrelor users (81.6%) were adherent during the study versus 5,256 of clopidogrel users (73.9%) (p < 0.001; χ2 = 86.4). Differences in other secondary outcomes were not statistically significant.


In this population-based cohort study of patients with ACS who underwent PCI, outpatient use of ticagrelor was not associated with a statistically significant reduction in MACE versus clopidogrel; however, it was associated with more major bleeding and dyspnea.


This is a retrospective analysis from a large, provincial database comparing clinical outcomes among patients receiving ticagrelor versus clopidogrel after PCI for ACS. Ticagrelor currently gets a stronger guideline recommendation than clopidogrel for ACS-related PCI. The current data excluded in-hospital outcomes and focused on outcomes at 1 year based on choice of P2Y12 inhibitor at the time of discharge. Clinical outcomes appear to be similar between the two drugs after discharge; however, there was increased bleeding and dyspnea among ticagrelor users. Adherence to dual antiplatelet therapy was more important in predicting outcomes than choice of P2Y12 inhibitor. Barring the limitations of a retrospective analysis, these data support use of either ticagrelor or clopidogrel and stress the importance of ensuring medical adherence with prescribed antiplatelet therapy.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and ACS, Aortic Surgery, Cardiac Surgery and Heart Failure, Interventions and ACS

Keywords: Acute Coronary Syndrome, Anticoagulants, Comorbidity, Coronary Disease, Dyspnea, Emergency Service, Hospital, Hemorrhage, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Stents, Thrombosis

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