Efficacy and Safety of Ticagrelor vs. Clopidogrel in East Asian Patients with Acute Myocardial Infarction: A Nationwide Cohort Study

Abstract

Ticagrelor improves clinical outcomes in patients with acute myocardial infarction (AMI). This study aimed to compare the efficacy and safety of ticagrelor vs. clopidogrel in East Asian patients with AMI. Between July 2013 and December 2015, patients with AMI prescribed dual antiplatelet therapy were identified from the National Health Insurance Research Database of Taiwan. Using propensity score weighting, ticagrelor was compared with clopidogrel for the primary efficacy end point (a composite of all‐cause death, myocardial infarction (MI), and stroke) and bleeding. A total of 32,442 patients with AMI (ticagrelor: 10,057; clopidogrel: 22,385) were eligible for analysis. After propensity score weighting, ticagrelor was comparable to clopidogrel in the incidence rate of the primary efficacy end point (23.6 vs. 22.76/100 patient‐years; hazard ratio (HR) 0.97; 95% confidence interval (CI) 0.89–1.06; P = 0.513). Ticagrelor was associated with a lower risk of stroke (1.78 vs. 2.66/100 patient‐years; HR 0.64; 95% CI 0.49–0.85; P = 0.002) and higher risks of overall (21.59 vs. 18.35/100 patient‐years; HR 1.16; 95% CI 1.06–1.27; P = 0.002) and Bleeding Academic Research Consortium (BARC) type 2 bleeding (18.67 vs. 15.08/100 patient‐years; HR 1.22; 95% CI 1.11–1.36; P < 0.001). The risks of death, MI, and BARC 3 or 5 bleeding were comparable between ticagrelor and clopidogrel. In the present study, ticagrelor was comparable to clopidogrel in the composite of death, MI, and stroke, but had an increased risk of BARC type 2 bleeding. Ticagrelor may be beneficial in preventing post‐MI stroke in East Asian patients.

Outcomes after ticagrelor versus clopidogrel treatment in end-stage renal disease patients with acute myocardial infarction: a nationwide cohort study

“…In the present study, ticagrelor was comparable to clopidogrel regarding the composite endpoint of all-cause death, MI, or stroke in patients with ESRD. This finding is consistent with the results of our recent study in a general AMI population in Taiwan 41 . Growing evidence shows that the risk–benefit ratio for antithrombotic therapy may be different between Caucasians and East Asians.…”

In-Hospital Bleeding in Elderly Patients With Acute Coronary Syndrome: Are Potent Antiplatelet Agents Safe?

“…17 The same concerns also apply for Asian patients where administration of ticagrelor seems to increase bleeding risk both in the short- and long-term, most likely owing to low body mass index. 18 Although current guidelines do not recommend prasugrel, another potent P2Y12 inhibitor to patients over 75°years of age, there is no restriction for ticagrelor. 19 In contrast, bleeding events do not seem to increase with potent P2Y12 inhibitors after discharge.…”

Ticagrelor vs. Clopidogrel After Complex Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease

“…The incidence of myocardial infarction in our study tended to be numerically higher in ticagrelor-treated patients, which might be partly explained by the great procedural complexity of patients receiving ticagrelor than clopidogrel. In addition to intensified DAPT, patients undergoing complex PCI who did not fulfill the criteria of high bleeding risk could significantly benefit from prolonged DAPT, while patients with high bleeding risk could not ( 23 ).…”

“…It was reported that the increased risk of ischemic events and mortality in patients who underwent complex PCI were further increased in those with >one element of the complexity criteria. However, the fulfillment of complex PCI criteria did not significantly affect bleeding risk ( 23 ). The fact that the correlation between PCI complexity and bleeding risk remains controversial might be explained in part by various definitions of complex PCI and different study populations across different studies ( 24 ).…”