Ticagrelor Loading on ST-Elevation Myocardial Infarction: Interaction With Prodromal Angina on Infarct Size and
João Pedro Faria1,2, Pedro Oliveira2,3, André Alexandre4
1Cardiovascular Research, UMIB-Unit for Multidisciplinary Research in Biomedicine, University of Porto, Porto, Portugal.
Insights
Ticagrelor reduced infarct size in ST-elevation myocardial infarction (STEMI) patients, independent of pre-infarction angina (PIA). However, clinical outcomes were similar compared to clopidogrel.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Pre-infarction angina (PIA) is a known preconditioning stimulus that mitigates ischemia-reperfusion injury.
- Ticagrelor's potential to reduce infarct size in ST-elevation myocardial infarction (STEMI) is attributed to its potent antiplatelet effects or a conditioning stimulus.
- The interaction between PIA and ticagrelor in STEMI patients remains under-explored.
Purpose of the Study:
- To compare clinical outcomes between STEMI patients loaded with ticagrelor versus clopidogrel.
- To investigate whether the presence of PIA modulates the effects of ticagrelor in STEMI patients.
- To assess the impact of ticagrelor and PIA on infarct size and major adverse cardiac and cerebrovascular events (MACCE).
Main Methods:
- Propensity score matching was used to analyze 826 STEMI patients treated with either clopidogrel or ticagrelor.
- Infarct size was estimated by peak creatine kinase (CK) and troponin T (TnT) levels.
- Clinical outcomes, including MACCE and survival, were evaluated at 1-year follow-up.
Main Results:
- Ticagrelor loading resulted in significantly lower peak CK and TnT levels, indicating reduced infarct size, irrespective of PIA.
- PIA was associated with lower CK levels but did not significantly impact TnT levels.
- No significant interaction was observed between ticagrelor loading and PIA regarding infarct size markers (TnT and CK).
- No significant differences in MACCE incidence or 1-year survival were found between the ticagrelor and clopidogrel groups, even when considering PIA.
Conclusions:
- Ticagrelor effectively reduces infarct size in STEMI patients, independent of PIA, without a synergistic effect.
- Despite reducing infarct size, ticagrelor did not lead to improved clinical outcomes (MACCE, survival) compared to clopidogrel in STEMI patients.
- The presence of PIA does not appear to modify the effect of ticagrelor on infarct size or clinical outcomes in this cohort.
Introduction:
Ticagrelor might reduce infarct size by exerting a more potent antiplatelet effect or by promoting a potential conditioning stimulus in ST-elevation myocardial infarction (STEMI) patients. Pre-infarction angina (PIA) is an effective preconditioning stimulus that reduces ischemia-reperfusion injury. Because little is known on the interaction of PIA in STEMI-patients loaded with ticagrelor, we sought to determine if patients loaded with ticagrelor had improved clinical outcomes as compared to clopidogrel and to study if it is modulated by the presence of PIA.
Methods:
From 1272 STEMI patients submitted to primary percutaneous coronary intervention and treated with clopidogrel or ticagrelor from January 2008 to December 2018, 826 were analyzed after propensity score matching. Infarct size was estimated using peak creatine kinase (CK) and troponin T (TnT), and clinical impact was evaluated through cumulative major cardiac and cerebrovascular events (MACCE) at 1-year follow-up. Matched patients and their interaction with PIA were analyzed.
Results:
Patients loaded with ticagrelor had lower peak CK [1405.50 U/L (730.25-2491.00), P < .001] and TnT [3.58 ng/mL (1.73-6.59), P < .001)], regardless of PIA. The presence of PIA was associated with lower CK (P = .030), but not TnT (P = .097). There was no interaction between ticagrelor loading and PIA (P = .788 for TnT and P = .555 for CK). There was no difference in MACCE incidence between clopidogrel or ticagrelor loading (P = .129). Cumulative survival was also similar between clopidogrel or ticagrelor, regardless of PIA (P = .103).
Conclusion:
Ticagrelor reduced infarct sizes independently and without a synergic effect with PIA. Despite reducing infarct size, clinical outcomes were similar across both groups.
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