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Ticagrelor versus clopidogrel in STEMI post-PCI: A mixed-design meta-analysis of efficacy and safety
Mohammad Maroof Shahid1, Muhammad Hamza Sajjad2, Sanket Kumar Pankajbhai Patel3
1Department of Cardiology, Services Institute of Medical Sciences, Lahore, Pakistan.
Insights
Ticagrelor significantly reduces mortality and MACE in STEMI patients post-PCI compared to clopidogrel. However, it is associated with increased target vessel revascularization, necessitating careful consideration in clinical practice.
Area of Science:
- Cardiology
- Pharmacology
- Interventional Cardiology
Background:
- ST-segment elevation myocardial infarction (STEMI) management involves primary percutaneous coronary intervention (PCI) and dual antiplatelet therapy (DAPT).
- Ticagrelor offers superior platelet inhibition compared to clopidogrel, but its comparative efficacy and safety in STEMI patients post-PCI remain debated.
Purpose of the Study:
- To systematically review and meta-analyze the efficacy and safety of ticagrelor versus clopidogrel in STEMI patients undergoing primary PCI.
- To compare key cardiovascular outcomes and bleeding events between ticagrelor and clopidogrel in this patient population.
Main Methods:
- A systematic review and meta-analysis following PRISMA 2020 guidelines.
- Searched major databases (PubMed, Embase, ScienceDirect, ClinicalTrials.gov) for RCTs and observational studies up to July 2025.
- Pooled data using random-effects models to calculate odds ratios (ORs) with 95% confidence intervals (CIs).
Main Results:
- Ticagrelor significantly reduced all-cause mortality (OR=0.64), cardiovascular mortality (OR=0.68), MACE (OR=0.71), MI (OR=0.71), and stent thrombosis (OR=0.66).
- Major bleeding risk was also reduced with ticagrelor (OR=0.87), but target vessel revascularization increased (OR=1.30).
- No significant difference in stroke risk was observed between the two agents.
Conclusions:
- Ticagrelor demonstrates superior efficacy over clopidogrel in reducing major adverse cardiovascular events and mortality in STEMI patients post-PCI.
- While ticagrelor offers significant benefits, the increased risk of target vessel revascularization requires careful clinical consideration and patient selection.
Background:
ST-segment elevation myocardial infarction (STEMI) requires primary percutaneous coronary intervention (PCI) and dual antiplatelet therapy with aspirin and a purinergic receptor Y12 inhibitor to reduce thrombotic risks. Ticagrelor, a potent purinergic receptor Y12 inhibitor, offers faster and stronger platelet inhibition than clopidogrel, but evidence on its efficacy and safety in STEMI patients post-PCI is conflicting. This study aims to compare the efficacy and safety of ticagrelor versus clopidogrel in STEMI patients undergoing primary PCI.
Methods:
This systematic review and meta-analysis, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, searched PubMed, Embase, ScienceDirect, and ClinicalTrials.gov up to July 2025. Included were randomized controlled trials and observational studies comparing ticagrelor to clopidogrel in adult STEMI patients post-PCI, reporting cardiovascular outcomes. Data were pooled using odds ratios (ORs) with 95% confidence intervals (CIs) via random-effects models.
Results:
Eight studies (5 randomized controlled trials, 3 observational; n = 31,729) showed ticagrelor significantly reduced all-cause mortality (OR = 0.64, 95% CI = 0.47-0.88; P = .006), cardiovascular mortality (OR = 0.68, 95% CI = 0.60-0.93; P = .01), major adverse cardiovascular events (OR = 0.71, 95% CI = 0.60-0.84; P = .01), myocardial infarction (OR = 0.71, 95% CI = 0.61-0.83; P < .00001), stent thrombosis (OR = 0.66, 95% CI = 0.55-0.79; P < .00001), and major bleeding (OR = 0.87, 95% CI = 0.78-0.97; P = .01), but increased target vessel revascularization (OR = 1.30, 95% CI = 1.05-1.61; P = .02). No significant difference was observed in stroke risk (OR = 1.16, 95% CI = 0.89-1.52; P = .28).
Conclusion:
Ticagrelor outperforms clopidogrel in STEMI post-PCI, reducing key adverse outcomes, though higher target vessel revascularization risk warrants caution.
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