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Angiographic outcomes in the PLATO Trial (Platelet Inhibition and Patient Outcomes)
Vijay Kunadian1, Stefan K James, Daniel M Wojdyla
1Department of Cardiology, Institute of Cellular Medicine, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals National Health Service Foundation Trust, Newcastle Upon Tyne, United Kingdom.
Insights
Ticagrelor and clopidogrel showed similar angiographic outcomes in acute coronary syndrome patients undergoing percutaneous coronary intervention. This study found no significant differences in coronary flow or myocardial perfusion between the two antiplatelet treatments.
Area of Science:
- Cardiology
- Pharmacology
- Interventional Cardiology
Background:
- Enhanced platelet inhibition is linked to improved angiographic outcomes post-percutaneous coronary intervention (PCI).
- Ticagrelor offers more rapid, potent, and consistent platelet inhibition compared to clopidogrel.
- The PLATO trial's angiographic substudy investigated ticagrelor's potential superiority over clopidogrel.
Purpose of the Study:
- To compare the efficacy of ticagrelor versus clopidogrel on angiographic outcomes before and after PCI.
- To evaluate myocardial perfusion and coronary flow in acute coronary syndrome patients receiving ticagrelor or clopidogrel.
Main Methods:
- The study included 2,616 patients from the PLATO trial undergoing PCI.
- Patients received either ticagrelor or clopidogrel, with specific dosing protocols before PCI.
- The primary endpoint was post-PCI Thrombolysis In Myocardial Infarction (TIMI) myocardial perfusion grade 3.
Main Results:
- Post-PCI TIMI myocardial perfusion grade 3 was similar between ticagrelor and clopidogrel groups (47.1% vs. 46.9%).
- Pre-PCI outcomes including TIMI flow grade, corrected TIMI frame count, and minimum lumen diameter were also comparable.
- No significant differences were observed in coronary flow or myocardial perfusion between the treatment groups.
Conclusions:
- Ticagrelor and clopidogrel demonstrated similar efficacy regarding coronary flow and myocardial perfusion after PCI in ACS patients.
- The observed angiographic outcomes did not differ significantly within a few hours of initiating oral antiplatelet therapy.
- These findings suggest no angiographic advantage of ticagrelor over clopidogrel in this specific patient population and time frame.
Objectives:
The PLATO (Platelet Inhibition and Patient Outcomes) angiographic substudy sought to compare the efficacy of ticagrelor versus clopidogrel with respect to angiographic outcomes before and after PCI in the setting of acute coronary syndrome.
Background:
Greater platelet inhibition has been associated with improved angiographic outcomes before and after percutaneous coronary intervention (PCI). Therefore, it was hypothesized that treatment with ticagrelor, which achieves more rapid, higher, and more consistent platelet inhibition, would be associated with improved angiographic outcomes when compared with those of clopidogrel treatment.
Methods:
The angiographic cohort consists of 2,616 patients drawn from the 18,624-patient PLATO trial. Clopidogrel naïve or pre-treated patients were randomized to 180 mg of ticagrelor or 300 mg of clopidogrel (75 mg for clopidogrel pre-treated patients). PCI patients were administered, as per treatment group: 1) an additional 90 mg of ticagrelor if >24 h following the initial loading dose; or 2) an optional further 300 mg of clopidogrel or placebo (total 600 mg) prior to PCI. The substudy primary endpoint was the incidence of post-PCI TIMI (Thrombolysis In Myocardial Infarction) myocardial perfusion grade 3 (TMPG 3) among patients who received a study drug prior to PCI.
Results:
In total, 21.3% of patients were pretreated with clopidogrel prior to randomization. There was a short time interval between randomization and PCI (median: 0.68 [interquartile range (IQR): 0.30 to 2.21] h) among all patients. Post-PCI TMPG 3 was similar between the ticagrelor and clopidogrel groups (47.1% vs. 46.9%; p = 0.96). Likewise, the following pre-PCI outcomes were similar in the ticagrelor and clopidogrel groups, respectively: TMPG 3 (30.5% vs. 31.2%), TIMI flow grade 3 (37.1% vs. 39.3%), corrected TIMI frame count (median: 100 vs. 71 frames), TIMI thrombus grade 0 (24.1% vs. 27.6%), minimum lumen diameter (median: 0.3 [IQR: 0.0 to 0.6] vs. 0.3 [IQR: 0.0 to 0.6] mm) and percentage of diameter stenosis (median: 89 [IQR: 78 to 100] vs. 89 [IQR: 77 to 100]).
Conclusions:
Neither coronary flow nor myocardial perfusion, evaluated on coronary angiograms performed before or following PCI procedures within a few hours after the start of oral antiplatelet treatment in the setting of acute coronary syndromes, demonstrated a difference with ticagrelor versus clopidogrel. (A Comparison of Ticagrelor [AZD6140] and Clopidogrel in Patients With Acute Coronary Syndrome [PLATO]; NCT00391872).
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