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Ticagrelor or clopidogrel dual antiplatelet therapy following a pharmacoinvasive strategy in ST-segment elevation
Robert C Welsh1,2,3, Jay S Shavadia1,4, Yinggan Zheng1,2,3
1Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
Insights
Switching STEMI patients from clopidogrel to ticagrelor after fibrinolysis significantly reduced 1-year ischemic events without increasing bleeding risk. This supports ticagrelor use in pharmacoinvasive STEMI treatment.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Many ST-elevation myocardial infarction (STEMI) patients require fibrinolysis due to delayed percutaneous coronary intervention (PCI).
- Previous studies show similar short-term safety for clopidogrel and ticagrelor, but long-term outcomes in pharmacoinvasive STEMI are less understood.
Purpose of the Study:
- To compare long-term outcomes in STEMI patients treated with fibrinolysis, comparing those sustained on clopidogrel versus those switched to ticagrelor.
- To evaluate the efficacy and safety of ticagrelor versus clopidogrel in a pharmacoinvasive STEMI strategy.
Main Methods:
- Observational cohort study of 1426 pharmacoinvasive STEMI patients.
- Comparison of patients switched to ticagrelor versus those maintained on clopidogrel post-fibrinolysis.
- Primary endpoint: 1-year composite of all-cause death, recurrent myocardial infarction, or stroke; safety outcomes included major bleeding and intracranial hemorrhage (ICH).
- Inverse probability weighting and multivariable Cox regression were used for analysis.
Main Results:
- 28% of patients were switched to ticagrelor.
- The primary composite endpoint occurred in 3.5% of ticagrelor patients versus 7.0% of clopidogrel patients (p=0.014).
- Ticagrelor use was associated with a 54% reduction in the composite outcome (adjusted HR 0.46).
- Major bleeding and ICH rates were similar between groups.
Conclusions:
- Switching to ticagrelor after fibrinolysis in STEMI patients significantly reduced 1-year recurrent ischemic events compared to maintaining clopidogrel.
- No significant difference in major bleeding or intracranial hemorrhage was observed between the two P2Y12 inhibitors.
- Findings support the use of ticagrelor in STEMI patients managed with a pharmacoinvasive approach.
Objectives:
To describe and evaluate outcomes in STEMI patients sustained on clopidogrel compared to those switched to ticagrelor following fibrinolysis.
Background:
World-wide, many STEMI patients cannot achieve timely PCI and therefore require fibrinolysis. Although comparable 30-day and 1-year safety was shown with clopidogrel or ticagrelor in the TREAT study, there is paucity of long-term outcomes in pharmacoinvasive treated STEMI.
Methods:
We conducted an observational cohort study evaluating consecutive pharmacoinvasive STEMI patients treated in a network, comparing those switched to ticagrelor to those sustained on clopidogrel. The primary efficacy composite was one-year all-cause death, recurrent myocardial infarction, and stroke with major bleeding and intracranial hemorrhage (ICH) as the safety outcomes. Multivariable Cox regression model was used to examine the association between P2Y12 inhibitor and outcomes with inverse probability weighting.
Results:
Of 1426 pharmacoinvasive STEMI patients, 28% (n = 396) were converted to ticagrelor at a mean of 9.9 h after fibrinolysis with comparable GRACE Risk Scores (median; 158 vs 157, p0.352). The primary composite occurred in 3.5% of ticagrelor and 7.0% of clopidogrel treated patients (p0.014). Following adjustment, ticagrelor was associated with a 54% lower composite outcome (adjusted HR 0.46, 95% confidence interval 0.26-0.84). Major bleeding 6.3% vs 6.1% (NS) and ICH 0.0% vs 0.2% (NS) were similar.
Conclusions:
In a prospective STEMI cohort, switching to ticagrelor compared with sustaining clopidogrel following fibrinolysis pharmacoinvasive reperfusion reduced recurrent ischemic events at 1-year with no differences in major bleeding or ICH. Aligned with randomized data, these findings provide support to switch pharmaco-invasively treated STEMI patients.
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