Comparison of P2Y₁₂ inhibitors for mortality and stent thrombosis in patients with acute coronary syndromes: Single center study of 10 793 consecutive ‘real-world’ patients

Abstract

Three oral platelet P2Y inhibitors, clopidogrel, prasugrel, and ticagrelor, are available for reducing the risk of cardiovascular death and stent thrombosis in patients with acute coronary syndromes (ACS). We sought to compare the efficacy of these antiplatelet drugs in contemporary practice. Data were collected for 10 793 consecutive ACS patients undergoing coronary angiography at Sheffield, UK (2009-2015). Since prasugrel use was mostly restricted to the STEMI subgroup, clopidogrel and ticagrelor were compared for all ACS patients, and all three agents were compared in the STEMI subgroup. Differences in outcomes were evaluated at 12 months by KM curves and log-rank test after adjustment for independent risk factors. Of 10 793 patients with ACS (36% STEMI), 43% (4653) received clopidogrel, 11% (1223) prasugrel and 46% (4917) ticagrelor, with aspirin for all. In the overall group, ticagrelor was associated with lower all-cause mortality compared with clopidogrel (adjusted hazard ratio (adjHR) 0.82, 95% confidence intervals (CI) 0.71-0.96, p = 0.01). In the STEMI subgroup, both prasugrel and ticagrelor were associated with a lower mortality compared with clopidogrel (prasugrel vs. clopidogrel: adjHR 0.65, CI 0.48-0.89, p = 0.007; ticagrelor vs. clopidogrel: adjHR 0.70, CI 0.61-0.99, p = 0.05). Of the 7595 patients who underwent PCI, 78 (1.0%) had definite stent thrombosis by 12 months. Patients treated with ticagrelor had a lower incidence of definite stent thrombosis compared with clopidogrel (0.6% vs. 1.1%; adjHR 0.51, CI 0.29-0.89, p = 0.03). In the STEMI subgroup, there was no significant difference between the three groups (ticagrelor 1.0%, clopidogrel = 1.5%, prasugrel = 1.6%; p = 0.29). In conclusion, ticagrelor was superior to clopidogrel for reduction in both mortality and stent thrombosis in unselected invasively managed ACS patients. In STEMI patients, both ticagrelor and prasugrel were associated with lower mortality compared with clopidogrel, but there was no significant difference in the incidence of stent thrombosis.

Effectiveness of new antiplatelets in the prevention of recurrent myocardial infarction

“…A study using the The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART)- Myocardial infarction (MI) (SWEDEHEART-MI)registry on 45 073 patients of whom about one-fourth were discharged on ticagrelor, the balance on clopidogrel, showed a cumulative probability of the combined outcome of death, MI and stroke at 24 months for patients in the ticagrelor cohort was half that of the clopidogrel cohort (11.7% (95% CI 10.6 to 12.8) vs 22.3% (95% CI 21.8 to 22.7)) 17. Furthermore, a recent study investigated the effect of prasugrel and ticagrelor on all-cause mortality and stent thrombosis in a large single-centre, all-comers registry to find that both prasugrel and ticagrelor were associated with reduced mortality compared with clopidogrel in patients with STEMI and that ticagrelor also significantly reduced the rate of stent thrombosis which is consistent with our results 18. Our findings are also consistent with studies providing platelet function measurement data, most of these concluding that, compared with prasugrel, ticagrelor was associated with significantly greater P2Y 12 inhibition with both achieving a significantly greater inhibition than clopidogrel during maintenance therapy 19 20…”

Prevalence of Chronic Kidney Disease, Thrombotic Cardiovascular Events, and Use of Oral P2Y₁₂ Inhibitors among Veterans

“…Interestingly, more than half of the total prescriptions for ticagrelor were prescribed to Veterans with CKD. Although, comparative effectiveness and safety data of P2Y12i were recently published in the general population reporting the superiority of ticagrelor over other P2Y12i, data remain limited among individuals with CKD, especially dialysis-dependent or pre-dialysis CKD with creatinine clearance <30 mL/min, to support these prescribing trends observed in the VA system [13].…”

The Use of Dual Antiplatelet Therapy in Acute Coronary Syndrome and Percutaneous Coronary Intervention

“…Механизм действия АСК основан на необратимом ингибировании фермента циклооксигеназы-1 [14]. Этот фермент участвует в превращении арахидоновой кислоты в простагландин H 2 внутри активированного тромбоцита.…”