Efficacy and Safety of Ticagrelor in Comparison to Clopidogrel in Elderly Patients With ST‐Segment–Elevation Myocardial Infarctions

Abstract

BackgroundCurrent guidelines recommend the new‐generation P2Y12‐inhibitor ticagrelor for patients with acute ST‐segment–elevation myocardial infarctions (STEMIs). The aim of the present study was to assess efficacy and safety of ticagrelor for elderly patients with STEMI (≥75 years) in an all‐comers STEMI registry.Methods and ResultsPatients with STEMI, aged ≥75 years, treated with primary percutaneous coronary intervention and documented in the Bremen STEMI Registry between 2006 and 2017 entered analysis. The primary efficacy outcome, major adverse cardiac and cerebrovascular events, was defined as a composite of death, myocardial reinfarction, and stroke. The safety outcome was defined as any significant bleeding event within 1 year. To estimate benefit/risk ratio, net adverse clinical events (major adverse cardiac and cerebrovascular events+bleedings) were calculated. Outcomes were estimated in propensity score–matched cohorts to adjust for possible confounders. Of a total of 7466 patients with STEMI, 1087, aged ≥75 years, were selected, of which 552 (51%) received clopidogrel and 535 (49%) received ticagrelor, with similar age (80.9±4.6 versus 80.9±4.6 years) and sex (51% versus 50% female) distributions between treatment arms. The primary efficacy outcome occurred in 32.4% of patients treated with clopidogrel versus 25.5% treated with ticagrelor (P=0.015), with the 1‐year mortality rate at 26.8% versus 21.1% (P=0.035). Because there was no difference in the safety outcome (clopidogrel versus ticagrelor, 4.9% versus 5.1%; not significant), net adverse clinical events were higher for clopidogrel than for ticagrelor: 37.3% versus 30.6% (P=0.028). In a propensity score–matched model, the advantage for ticagrelor on major adverse cardiac and cerebrovascular events remained significant (hazard ratio, 0.69; 95% CI, 0.49‐0.97; P=0.03), whereas 1‐year‐mortality (hazard ratio, 0.89; 95% CI, 0.67–1.27; P=0.5) and 1‐year bleeding events (hazard ratio, 1.1; 95% CI, 0.4–2.3; P=0.8) did not differ.ConclusionsThese results from propensity score–matched registry data show that for elderly patients with STEMI, ticagrelor compared with clopidogrel was associated with a reduction in major adverse cardiac and cerebrovascular events without a significant increase in bleeding events within 1 year.

Aspirin, clopidogrel and prasugrel monotherapy in patients with type 2 diabetes mellitus: a double-blind randomised controlled trial of the effects on thrombotic markers and microRNA levels

“…Additionally, there is evidence that potent P2Y 12 inhibition may offer benefits in patients with T2DM and complications such as lower extremity arterial disease, in which ticagrelor improves microvascular flow, for example [45]. Although there has been concern over greater bleeding risk increasing the potency of P2Y 12 inhibition, recent evidence suggests, for example, ticagrelor may have similar safety to clopidogrel in patients at high risk of bleeding, such as those who are elderly with ST-elevation myocardial infarction [46], and low-dose prasugrel appears to be of comparable safety to clopidogrel when used in triple therapy (aspirin, P2Y 12 inhibitor and anticoagulant) for patients with atrial fibrillation undergoing percutaneous coronary intervention [47].…”

Ticagrelor as an Alternative Antiplatelet Therapy in Cardiac Patients Non-Sensitive to Aspirin

“…Ticagrelor, a “next generation” P2Y12 receptor inhibitor is an alternative antiplatelet therapy commonly prescribed to patients with CAD. It has demonstrated its efficacy as an antiplatelet medication when compared with ASA and clopidogrel [ 20 , 43 ]. The THEMIS trial conducted by Steg et al in 2019 demonstrated that patients with stable CAD and diabetes benefited from taking ticagrelor in combination with ASA, compared to ASA and a placebo [ 23 ].…”

“…Ticagrelor is an alternative antiplatelet therapy that is commonly prescribed to patients with acute coronary syndrome (ACS), defined as patients with unstable angina, non-ST-segment elevation myocardial infarctions (NSTEMI), or ST-segment elevation myocardial infarctions (STEMI), as well as patients with a previous history of myocardial infarction (MI) [ 19 , 20 , 21 ]. This medication binds to, and reversibly inhibits the P2Y12 adenosine diphosphate (ADP) receptor on platelets, inhibiting ADP-induced platelet aggregation [ 22 ].…”

No Differences in Gastrointestinal Bleeding Risk among Clopidogrel-, Ticagrelor-, or Prasugrel-Based Dual Antiplatelet Therapy

“…In this study, as previously described [23,[26][27][28], we have confirmed that in clinical practice, the baseline characteristics of patients taking clopidogrel-DAPT are significantly different from those in treatment with new antiplatelet-DAPT. In European registries [23], patients treated with prasugrel are usually younger than those treated with ticagrelor [31], and patients treated with clopidogrel are older, with almost 10 years of difference in some studies. Danchin et al [23] showed that older age is usually associated with more comorbidities and higher cardiovascular risk, as we confirm in our study.…”