Frailty and Clinical Outcomes of Ticagrelor Versus Clopidogrel in Older Adults With Acute Myocardial Infarction
Darae Ko1,2, Peter T Evans2, Kueiyu Joshua Lin3,4
1Hinda and Arthur Marcus Institute for Aging Research Hebrew SeniorLife Boston MA.
Insights
Ticagrelor showed a trend toward fewer cardiovascular events but more bleeding in non-frail older adults compared to clopidogrel. Evidence for ticagrelor benefit in frail individuals was insufficient.
Area of Science:
- Cardiology
- Geriatrics
- Pharmacology
Background:
- Ticagrelor is recommended for acute coronary syndrome (ACS) over clopidogrel based on the PLATO trial.
- This study emulates the PLATO trial in older adults, considering frailty status.
Purpose of the Study:
- To compare the effectiveness and safety of ticagrelor versus clopidogrel in older adults with ACS undergoing percutaneous coronary intervention (PCI).
- To investigate the impact of frailty on treatment outcomes.
Main Methods:
- A new-user cohort of Medicare beneficiaries aged ≥65 years hospitalized for ACS (2014-2018) was analyzed.
- Frailty was assessed using a claims-based index (≥0.25).
- Propensity score matching was used to compare major adverse cardiovascular events (MACE) and major bleeding between ticagrelor and clopidogrel users.
Main Results:
- Among non-frail adults, ticagrelor showed a trend towards reduced MACE (HR 0.87) and increased bleeding (HR 1.22) compared to clopidogrel.
- In the frail cohort, no significant difference in MACE (HR 1.07) or bleeding (HR 1.12) was observed between the two drugs.
Conclusions:
- Ticagrelor may offer a modest benefit in reducing cardiovascular events but increases bleeding risk in non-frail older adults with ACS.
- Insufficient evidence exists to support ticagrelor's benefit in frail older adults undergoing PCI.
Background:
Ticagrelor is recommended over clopidogrel in acute coronary syndrome based on the results of the PLATO (Study of Platelet Inhibition and Patient Outcomes) trial. We aimed to emulate PLATO in older adults with and without frailty and with acute coronary syndrome treated with percutaneous coronary intervention.
Methods And Results:
We created a new-user cohort of Medicare fee-for-service beneficiaries aged ≥65 years hospitalized for acute coronary syndrome from 2014 to 2018 and initiated ticagrelor or clopidogrel following percutaneous coronary intervention. Frailty was defined using a validated claims-based frailty index ≥0.25. Coprimary outcomes were major adverse cardiovascular events and major bleeding. Follow-up began on the date of first outpatient prescription for ticagrelor or clopidogrel and ended on the earliest date for an outcome event, death, discontinuation of the index drug, or disenrollment from Medicare. The study included 42 843 older adults; 23% were frail. After propensity score matching, the rates of major adverse cardiovascular events per 100 person-years comparing ticagrelor versus clopidogrel groups were 7.8 and 7.3 in the frail cohort (hazard ratio [HR], 1.07 [95% CI, 0.84-1.36]) and 3.7 and 4.2 in the nonfrail cohort (HR, 0.87 [95% CI, 0.75-1.02]). The corresponding rates of major bleeding were 4.3 and 3.8 in the frail cohort (HR, 1.12 95% CI, [0.80-1.56]) and 2.2 and 1.8 in the nonfrail cohort (HR, 1.22 [95% CI, 0.98-1.51]).
Conclusions:
There was a trend toward a modest reduction in risk of major adverse cardiovascular events and a trend toward a modest increase in risk of major bleeding with ticagrelor compared with clopidogrel in the nonfrail cohort. There was insufficient evidence for the benefit of ticagrelor in frail older adults.
