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Ticagrelor versus Clopidogrel in Acute Coronary Syndrome Patients with High Ischemic and Bleeding Risk after
Kun Na1, Miaohan Qiu1, Tianai Zhang1
1Cardiovascular Research Institute, General Hospital of Northern Theater Command, Department of Cardiology, Liaoning, China, Shenyang.
Insights
For acute coronary syndrome patients with high ischemic and bleeding risks after stent implantation, ticagrelor did not lower adverse events but increased bleeding compared to clopidogrel. Individualized P2Y12 inhibitor selection is crucial.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Patients with acute coronary syndrome (ACS) often present with high ischemic and bleeding risks after percutaneous coronary intervention (PCI).
- Limited evidence exists to guide P2Y12 inhibitor selection in these dual high-risk patients undergoing drug-eluting stent (DES) implantation.
- The OPT-BIRISK criteria identify patients with both high ischemic and high bleeding risks.
Purpose of the Study:
- To compare the efficacy and safety of ticagrelor versus clopidogrel in ACS patients with dual high-risk criteria after DES implantation.
- To evaluate the impact of P2Y12 inhibitor choice on net adverse clinical events (NACE) and bleeding.
Main Methods:
- Retrospective analysis of a single-center PCI registry (March 2019-March 2022).
- Included ACS patients with new-generation DES implantation meeting OPT-BIRISK dual high-risk criteria.
- Propensity score overlap weighting adjusted for confounding factors.
- Primary endpoint: 12-month NACE (all-cause death, myocardial infarction, stroke, or BARC type 3 or 5 bleeding).
Main Results:
- The cohort included 20,213 dual high-risk patients (22.6% ticagrelor, 77.4% clopidogrel).
- NACE rates were similar between groups (4.58% vs. 5.21%; aHR, 1.05; P=.568).
- Ticagrelor was associated with higher BARC type 3 or 5 bleeding (2.17% vs. 1.57%; aHR, 1.39; P=.009) but not reduced ischemic events.
- Exploratory analysis showed higher NACE with ticagrelor in patients ≥75 years (P-interaction=.04).
Conclusions:
- In dual high-risk ACS patients after DES implantation, ticagrelor-based therapy showed higher bleeding risk without improving NACE or ischemic outcomes compared to clopidogrel.
- These findings suggest the need for individualized P2Y12 inhibitor selection.
- Prospective studies are warranted to confirm these observational results.
Abstract:
Patients with acute coronary syndrome (ACS) who have concurrent high ischemic and high bleeding risk are common after percutaneous coronary intervention (PCI), yet evidence guiding P2Y12 inhibitor selection remains limited. We compared ticagrelor and clopidogrel in ACS patients meeting OPT-BIRISK dual high-risk criteria after drug-eluting stent (DES) implantation.We retrospectively analyzed a single-center PCI registry. ACS patients undergoing new-generation DES implantation (March 2019-March 2022) who met both high ischemic and high bleeding risk criteria were classified by discharge P2Y12 inhibitor. Propensity score overlap weighting was adjusted for confounding. The primary endpoint was 12-month net adverse clinical events (NACE): all-cause death, myocardial infarction, stroke, or Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding.The final cohort comprised 20,213 dual high-risk patients (ticagrelor, 4,563 [22.6%]; clopidogrel, 15,650 [77.4%]). NACE was similar between groups (4.58% vs. 5.21%; adjusted hazard ratio [aHR], 1.05; 95% confidence interval [CI], 0.89-1.23; p = 0.568). Ticagrelor was not associated with reduced ischemic events (aHR, 0.90; 95% CI, 0.72-1.12; p = 0.333) but with higher BARC type 3 or 5 bleeding (2.17% vs. 1.57%; aHR, 1.39; 95% CI, 1.08-1.77; p = 0.009). In exploratory subgroup analysis, ticagrelor was associated with higher NACE in patients aged 75 years or older (p-Value for interaction = 0.04).In dual high-risk ACS patients undergoing DES implantation, discharge ticagrelor-based dual antiplatelet therapy was associated with higher bleeding risk without reducing NACE or ischemic events compared with clopidogrel. These observational findings support individualized P2Y12 inhibitor selection and warrant prospective confirmation.
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