Ticagrelor vs Clopidogrel in Clopidogrel-Naive Patients With Chronic Coronary Syndrome
Stéphane Manzo-Silberman1, Paul Guedeney1, Guillaume Cayla2
1Sorbonne Université, Allies in Cardiovascular Trials Initiatives and Organized Networks (ACTION) Study Group, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France.
Insights
Ticagrelor did not reduce periprocedural myocardial necrosis in elective percutaneous coronary intervention (PCI) patients. Clopidogrel-naive patients had fewer complications, but this was due to lower risk profiles, not the P2Y12 inhibitor used.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- Periprocedural myocardial necrosis after elective percutaneous coronary intervention (PCI) is a concern.
- The comparative efficacy of ticagrelor versus clopidogrel in patients with or without prior clopidogrel therapy remains unclear.
Purpose of the Study:
- To compare ticagrelor and clopidogrel in patients undergoing elective PCI.
- To assess the impact of prior clopidogrel therapy on outcomes.
Main Methods:
- A prespecified analysis of the ALPHEUS trial.
- Patients were categorized as clopidogrel-naive or clopidogrel-treated (≥7 days prior).
- Primary endpoint: composite of PCI-related myocardial infarction and major injury within 48 hours.
Main Results:
- 1,882 patients were analyzed; 42.7% were clopidogrel-treated.
- Clopidogrel-naive patients had lower rates of the primary endpoint (32.8% vs. 40.0%).
- Ticagrelor did not reduce periprocedural myocardial necrosis or adverse outcomes compared to clopidogrel, irrespective of prior treatment.
Conclusions:
- Clopidogrel-naive patients experienced fewer periprocedural complications due to lower risk profiles and less complex PCI.
- Baseline clopidogrel status did not alter the similar efficacy of ticagrelor and clopidogrel regarding PCI-related complications.
- Clopidogrel remains a standard of care for elective PCI in patients with or without chronic clopidogrel treatment.
Background:
Whether ticagrelor may reduce periprocedural myocardial necrosis after elective percutaneous coronary intervention (PCI) in patients with and without chronic clopidogrel therapy is unclear.
Objectives:
This study sought to compare ticagrelor vs clopidogrel in patients with and without chronic clopidogrel therapy before undergoing elective PCI.
Methods:
In this prespecified analysis of the ALPHEUS (Assessment of Loading With the P2Y12 Inhibitor Ticagrelor or Clopidogrel to Halt Ischemic Events in Patients Undergoing Elective Coronary Stenting) trial, patients were defined as clopidogrel(+) and clopidogrel(-) according to the presence and absence of clopidogrel treatment for ≥7 days before PCI, respectively. The primary endpoint was the composite of PCI-related myocardial infarction and major injury as defined by the third and fourth universal definition 48 hours after PCI.
Results:
A total of 1,882 patients were included, 805 (42.7%) of whom were clopidogrel(+). These patients were older, had more comorbidities, and had more frequent features of complex PCI. The primary endpoint was less frequently present in clopidogrel(-) compared to clopidogrel(+) patients (32.8% vs 40.0%; OR: 0.73; 95% CI: 0.60-0.88), but no significant differences were reported for the risk of death, myocardial infarction, stroke, or transient ischemic attack at 48 hours or 30 days. Ticagrelor did not reduce periprocedural myocardial necrosis or the risk of adverse outcomes, and there was no significant interaction regarding the presence of chronic clopidogrel treatment.
Conclusions:
Clopidogrel-naive patients presented less periprocedural complications compared to clopidogrel(+) patients, a difference related to a lower risk profile and less complex PCI. The absence of clopidogrel at baseline did not affect the absence of a difference between ticagrelor and clopidogrel in terms of PCI-related complications supporting the use of clopidogrel as the standard of care in elective PCI in patients with or without chronic clopidogrel treatment.
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