Comparison Between Ticagrelor and Clopidogrel in Elderly Patients With an Acute Coronary Syndrome

Abstract

Background: The comparative efficacy and safety of ticagrelor vs. clopidogrel in older myocardial infarction (MI) patients has received limited study. Methods: We performed an observational analysis of all patients ≥80 years (n=14005) who were discharged alive with aspirin combined with either clopidogrel (60.2%) or ticagrelor (39.8%) after a MI between 2010 and 2017 registered in the national registry Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). Inverse probability treatment weighting was used in Cox regression models to adjust for differences in demographics, in-hospital therapies, and medications. The primary ischemic outcome (death, MI or stroke), and bleeding were obtained from national registries at 1 year. A sensitivity analysis in <80-year-old patients was performed. Results: In patients ≥80 years, the incidence of the primary ischemic outcome (HR 0.97, 95% CI 0.88-1.06) was similar for ticagrelor- and clopidogrel-treated patients. Ticagrelor was associated with a 17% and 48% higher risk of death (1.17 (1.03- 1.32)) and bleeding (1.48 (1.25- 1.76)), but a lower risk of MI (0.80 (0.70- 0.92)) and stroke (0.72 (0.56-0.93)). In <80-year-old patients the incidence of the primary ischemic outcome was 17% (0.83 (0.77-0.89)) lower with ticagrelor. Ticagrelor was associated with 15% (0.85 (0.76-0.96)) lower risk of death, 32% higher risk of bleeding (1.32 (1.18-1.47)), but lower risk of MI (0.82 (0.75-0.91)) and stroke (0.82 (0.69-0.98)). Conclusions: Ticagrelor use among elderly MI patients was associated with higher risk of bleeding and death compared with clopidogrel. A randomized study of ticagrelor vs clopidogrel in the elderly is needed.

The value of evaluating and implementing pharmaceuticals

“…A Swedish based observational study supported the effectiveness of ticagrelor; 174 however, more recent studies have questioned the effectiveness of ticagrelor when used in clinical practice. [175][176][177][178][179] This is clearly relevant for the results of our case study since effectiveness estimates are central to the value that ticagrelor provide. Paper 4 investigates this particular issue.…”

“…160,163 However, observational studies on ticagrelor use in clinical practice has produced varying and conflicting evidence on ticagrelor effectiveness. [175][176][177][178][179][181][182][183][184] Some studies have found positive effects from ticagrelor when used in clinical practice, including a study by Sahlén et al (2016) who analysed data collected as part of Swedish routine clinical practice. 174 Other studies have found zero and even negative effects of ticagrelor use in clinical practice, including a recent study by Szummer et al (2020) who found an increased risk of mortality associated with ticagrelor in patients above 80 years of age.…”

“…[175][176][177][178][179][181][182][183][184] Some studies have found positive effects from ticagrelor when used in clinical practice, including a study by Sahlén et al (2016) who analysed data collected as part of Swedish routine clinical practice. 174 Other studies have found zero and even negative effects of ticagrelor use in clinical practice, including a recent study by Szummer et al (2020) who found an increased risk of mortality associated with ticagrelor in patients above 80 years of age. [175][176][177][178][179] The studies by Sahlén et al (2016) and Szummer et al (2020) both used data from the SWEDEHEART registry collecting information on patients hospitalised for acute coronary syndrome or receiving vascular or coronary interventions for other reasons.…”

A Case of Intraparenchymal Hepatic Hemorrhage Due to Ticagrelor Loading Treatment in an Elderly Patient With Acute Coronary Syndrome

“…According to the Swedish Web-system for Enhancement and Development of Evidencebased care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) records, it was reported that at the age of 80 years and above ticagrelor decreased ischemic events and stroke rates compared to clopidogrel, but significantly increased death and bleeding complications. However, it has been emphasized that there is a need for randomized studies, especially in elderly patients [11]. In the light of these data, it would be reasonable to routinely evaluate the application of clopidogrel de-escalation during the in-hospital stay 24 hours after the index event without such adverse events, especially in elderly patients who are prone to complications.…”

Entwicklung kardiovaskuläre Medizin 2020

“…Im 1-Jahres-Verlauf hatten die Patienten des Clopidogrel-Arms weniger Blutungskomplikationen ohne eine Zunahme des kombinierten Endpunkts von Gesamtsterblichkeit, Myokardinfarkt, Schlaganfall und Blutung. Die Ergebnisse der POPular-AGE-Studie werden durch eine Subanalyse des SWEDEHEART(Swedish Websystem for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies)-Registers bestätigt [20]. In dieser Analyse war Ticagrelor bei alten Patienten (≥80 Jahre) im Vergleich zu Clopidogrel mit einem höheren Risiko von Blutungen und einer erhöhten Sterblichkeit verbunden.…”