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Bleeding Outcomes of Ticagrelor Versus Clopidogrel in Acute Coronary Syndrome Patients: A Multiethnic Database Study
Guek Leng Loh1, Kok Joon Chong2, Ganga Ganesan3
1Department of Pharmacy, Ng Teng Fong General Hospital, Singapore.
Insights
Ticagrelor use in South-East Asian patients with acute coronary syndrome (ACS) was linked to a higher risk of bleeding complications compared to clopidogrel. Age, comorbidities, and ethnicity were identified as key bleeding predictors.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- East Asian populations exhibit distinct responses to P2Y12 inhibitors compared to Caucasians.
- Understanding these differences is crucial for optimizing antiplatelet therapy in acute coronary syndrome (ACS).
Purpose of the Study:
- To compare bleeding outcomes between ticagrelor and clopidogrel in a multiethnic South-East Asian ACS cohort.
- To identify independent predictors of bleeding events in this patient population.
Main Methods:
- A retrospective, propensity-matched, nationwide cohort study was conducted in Singapore.
- 14,812 ACS patients undergoing coronary revascularization were analyzed for 1-year bleeding outcomes.
- Multivariate logistic regression identified independent bleeding predictors.
Main Results:
- Ticagrelor use was associated with a significantly higher risk of any clinically relevant bleeding (aHR: 1.20) and BARC type 3 bleeding (aHR: 1.33) compared to clopidogrel.
- Independent predictors of bleeding included ticagrelor use, age ≥65, comorbidities (COPD, hyperlipidemia, CKD), anemia, prior bleeding, and concurrent oral anticoagulant use.
- Indian and 'other' ethnicities showed lower bleeding odds, while Malay and Chinese ethnicities had similar odds.
Conclusions:
- Ticagrelor increases the risk of BARC type 3 bleeding compared to clopidogrel in South-East Asian ACS patients.
- Novel bleeding risk factors include protective effects of Indian and 'other' ethnicity, and increased odds associated with advanced age, comorbidities, and specific conditions.
- Prospective studies are needed to validate these findings.
Background:
Compared with Caucasians, East Asians with acute coronary syndrome (ACS) respond differently to P2Y12 inhibitors.
Objectives:
The purpose of this study was to compare bleeding outcomes between ticagrelor and clopidogrel, and identify bleeding predictors in a multiethnic South-East Asian ACS cohort.
Methods:
We conducted a retrospective, propensity-matched, nationwide database cohort study of ACS patients who underwent coronary revascularization in Singapore, and compared 1-year bleeding outcomes of ticagrelor and clopidogrel. Independent bleeding predictors were investigated using multivariate logistic regression analysis.
Results:
Between January 2013 and December 2017, 14,812 ACS patients (8,502 [57%] clopidogrel and 6,310 [43%] ticagrelor) were eligible for the study. Median follow-up was 12 months (Q1-Q3: 12-12 months). Ticagrelor was associated with higher risk of any clinically relevant bleeding (adjusted HR: 1.20; 95% CI: 1.02-1.40; P = 0.022), particularly Bleeding Academic Research Consortium (BARC) type 3 bleeding (adjusted HR: 1.33; 95% CI: 1.04-1.69; P = 0.023), compared with clopidogrel. Independent bleeding predictors were ticagrelor use, age ≥65 years, increasing comorbidities, chronic obstructive pulmonary disease, hyperlipidemia, severe chronic kidney disease, anemia, prior bleeding within 6 months, and concurrent oral anticoagulant use. Indians and "others" experienced lower bleeding odds than Chinese, while Malays and Chinese had similar odds.
Conclusions:
Ticagrelor was associated with increased risk of BARC type 3 bleeding compared with clopidogrel. Novel risk factors Indian and "other" ethnicity appeared protective, while age ≥65 years, increasing comorbidities, chronic obstructive pulmonary disease, and hyperlipidemia were associated with increased bleeding odds. These novel bleeding risk factors warrant validation in a prospective study.
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