Switching from Ticagrelor to Clopidogrel in Asian Patients with ST-Elevated Myocardial Infarction - A Time Dependent
Leroy Koh1, Ji Heon Kim1, Su Yin Doreen Tan1
1Department of Pharmacy.
Insights
Switching from ticagrelor to clopidogrel after ST-elevated myocardial infarction (STEMI) in Asian patients showed no significant difference in major adverse cardiac events. However, switching may reduce clinically significant bleeding and offer cost savings.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Ticagrelor is a common initial treatment for ST-elevated myocardial infarction (STEMI).
- Switching to clopidogrel post-STEMI is practiced, but evidence on optimal timing and outcomes is conflicting.
- Real-world data on antiplatelet de-escalation strategies in Asian populations are limited.
Purpose of the Study:
- To investigate the safety and efficacy of switching from ticagrelor to clopidogrel in Asian STEMI patients.
- To analyze outcomes at various switch points in a real-world setting.
- To compare major adverse cardiac and cerebrovascular events (MACCEs) and clinically significant bleeding (CSB) between patients who switched and those who did not.
Main Methods:
- Retrospective cohort study of 349 STEMI patients treated with ticagrelor and aspirin.
- Follow-up duration of 1 year post-percutaneous coronary intervention (PCI).
- Cox regression analysis with switch status as a time-dependent covariate to assess MACCEs and CSB.
Main Results:
- No significant difference in MACCEs or CSB between the ticagrelor-to-clopidogrel switch group and the continued ticagrelor group (10.0% vs. 13.8%).
- No significant difference in MACCEs alone (2.3% vs. 7.7%).
- The switched group showed a statistically significant reduction in clinically significant bleeding (CSB) (7.8% vs. 8.5%; HR=0.298; p=0.047).
Conclusions:
- Switching from ticagrelor to clopidogrel in Asian STEMI patients is safe and does not compromise efficacy.
- De-escalation to clopidogrel may reduce the incidence of clinically significant bleeding.
- This strategy could lead to cost savings for Asian patients without compromising cardiovascular safety.
Background:
Ticagrelor is initially prescribed after an ST-elevated myocardial infarction (STEMI) and this may be followed by a switch to clopidogrel. However, studies involving antiplatelet switching have been conflicting and only assessed at a specific switch point. The objective of this study was to investigate switching from ticagrelor to clopidogrel in an Asian population, after accounting for various switch points as in a real-world environment.
Methods:
A retrospective cohort of 349 STEMI patients started on ticagrelor and aspirin were followed-up for 1 year after a percutaneous coronary intervention that was performed between June 2014 and November 2016. Patients who switched to clopidogrel were compared with those who remained on ticagrelor. Outcomes measured were major adverse cardiac and cerebrovascular events (MACCEs) and clinically significant bleeding (CSB). Cox regression analysis with switch status as a time-dependent covariate was performed.
Results:
The switched group was not associated with MACCEs or CSB [10.0% vs. 13.8%; hazard ratio (HR) = 0.484; 95% confidence interval (CI): 0.196-1.191; p = 0.114]. There was also no significant difference when MACCEs were analyzed alone (2.3% vs. 7.7%; HR = 0.518; 95% CI: 0.137-1.957; p = 0.332). For CSB, the switched group was less likely to have an event (7.8% vs. 8.5%; HR = 0.298; 95% CI: 0.091-0.982; p = 0.047).
Conclusions:
This study showed no significant difference between staying on ticagrelor and switching to clopidogrel. Switching might decrease the incidence of CSB. De-escalation from ticagrelor to clopidogrel could translate to cost savings for Asian patients without compromising safety and efficacy.
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