Safety and effectiveness of the new P2Y12r inhibitor agents vs clopidogrel in ACS patients according to the geographic area: East Asia vs Europe

Efficacy and safety of ticagrelor and clopidogrel in East Asian patients with coronary artery disease undergoing percutaneous coronary intervention

AIMS

The efficacy and safety of ticagrelor and clopidogrel in East Asian patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) remains uncertain. The purpose of this study was to compare the efficacy and safety of ticagrelor and clopidogrel in East Asian patients with CAD treated with PCI.

METHODS

A total of 12383 patients with CAD undergoing PCI who received dual antiplatelet therapy (DAPT) were consecutively enrolled in the ticagrelor group (n = 1321) and the clopidogrel group (n = 11062). Major adverse cardiovascular and cerebrovascular events (MACCEs) and thrombolysis in myocardial infarction (TIMI) bleeding events were compared according to ticagrelor or clopidogrel use were compared.

RESULTS

After propensity matching (n = 1321 in each group), ticagrelor was associated with lower incidence of MACCEs compared with clopidogrel (3.9 vs. 5.9%, hazard ratio [HR] = 0.65, 95% confidence interval [CI] 0.45-0.92, p = .015). The incidence of TIMI bleeding events was higher in the ticagrelor group than in the clopidogrel group (4.5 vs. 2.9%, HR = 1.90, 95% CI 1.25-2.88, p = .024). The difference between ticagrelor and clopidogrel for net adverse clinical events was nonsignificant (4.3 vs. 4.9%, HR = 0.88, 95% CI 0.61-1.27, p = .458).

CONCLUSIONS

Ticagrelor was associated with a lower incidence of MACCEs and an increased risk of TIMI bleeding events in East Asian patients with CAD receiving PCI.

1-year results after PCI with the COMBO stent in all-comers in Asia versus Europe: Geographical insights from the COMBO collaboration

BACKGROUND

The COMBO drug-eluting stent combines sirolimus-elution from a biodegradable polymer with an anti-CD34+ antibody coating for early endothelialization.

OBJECTIVE

We investigated for geographical differences in outcomes after percutaneous coronary intervention (PCI) with the COMBO stent among Asians and Europeans.

METHODS

The COMBO Collaboration is a pooled patient-level analysis of the MASCOT and REMEDEE registries of all-comers undergoing attempted COMBO stent PCI. The primary outcome was 1-year target lesion failure (TLF), composite of cardiac death, target vessel myocardial infarction (TV-MI) and target lesion revascularization (TLR).

RESULTS

This study included 604 Asians (17.9%) and 2775 Europeans (82.1%). Asians were younger and included fewer females, with a higher prevalence of diabetes mellitus but lower prevalence of other comorbidities than Europeans. Asians had a higher prevalence of ACC/AHA C type lesions and received longer stent lengths. More Asians than Europeans were discharged on clopidogrel (86.5% vs 62.8%) rather than potent P2Y₁₂ inhibitors. One-year TLF occurred in 4.0% Asians and 4.1% of Europeans, p = 0.93. The incidence of cardiac death was higher in Asians (2.8% vs. 1.3%, p = 0.007) with similar rates of TV-MI (1.5% vs. 1.2%, p = 0.54) and definite stent thrombosis (0.3% vs. 0.5%, p = 0.84) and lower incidence of TLR than Europeans (1.0% vs. 2.5%, p = 0.025). After adjustment, differences for cardiac death and TLR were no longer significant.

CONCLUSIONS

In the COMBO collaboration, although 1-year TLF was similar regardless of geography, Asians experienced higher rates of cardiac death and lower TLR than Europeans, while incidence of TV-MI and ST was similar in both regions. Adjusted differences did not reach statistical significance. CLINICALTRIAL.

GOV IDENTIFIER-NUMBERS

NCT01874002 (REMEDEE Registry), NCT02183454 (MASCOT registry).

Safety and Effectiveness of Contemporary P2Y12 Inhibitors in an East Asian Population With Acute Coronary Syndrome: A Nationwide Population-Based Cohort Study

Background

Prior reports indicate that the effect of P2Y₁₂ inhibitors may be different in East Asian patients (“East Asian paradox”); therefore, understanding the outcomes associated with potent P2Y₁₂ inhibitors in different populations is clinically important.

Methods and Results

In this observational cohort study using administrative healthcare data sets, we compared safety and effectiveness of contemporary P2Y₁₂ inhibitors in patients with acute coronary syndrome. The primary safety outcomes were major and any bleeding, and the primary effectiveness outcomes were major cardiovascular events (a composite of cardiovascular death, myocardial infarction, or stroke) and all‐cause mortality. Among 70 715 patients with acute coronary syndrome, 56 216 (79.5%) used clopidogrel, 11 402 (16.1%) used ticagrelor, and 3097 (4.4%) used prasugrel. The median follow‐up period was 18.0 months (interquartile range: 9.6–26.4 months). In a propensity‐matched cohort, compared with clopidogrel, ticagrelor was associated with a higher risk of any bleeding (hazard ratio: 1.23; 95% CI, 1.14–1.33) but a lower risk of mortality (hazard ratio: 0.76; 95% CI, 0.63–0.91). Prasugrel, compared with clopidogrel, was associated with higher risks of any bleeding (hazard ratio: 1.23; 95% CI, 1.06–1.43) and major bleeding (hazard ratio: 1.50; 95% CI, 1.01–2.21) but a similar risk of effectiveness outcomes. No significant difference was noted between ticagrelor and prasugrel with respect to key safety or effectiveness outcomes. Several sensitivity analyses showed similar results.

Conclusions

In East Asian patients with acute coronary syndrome, compared with clopidogrel, ticagrelor was associated with an increased risk of bleeding but a decreased risk of mortality. Prasugrel was associated with an increase of any bleeding without difference in effectiveness outcomes. The risks of bleeding and ischemic events were similar between ticagrelor and prasugrel.

2018 update of expert consensus statement on antiplatelet therapy in East Asian patients with ACS or undergoing PCI

East Asians are the most populous race in the world and their health status is an important global issue. Compared with Caucasian populations, East Asian patients have a different benefit/risk ratio when using antithrombotic treatment. Despite this observation, treatment strategies in East Asian patients are mostly based on the American and European guidelines. Despite a lower platelet inhibitory response to clopidogrel, East Asian patients show a similar or even a lower rate of ischemic event occurrence and higher bleeding risk compared with Caucasian patients. For potent P2Y₁₂ inhibitors (ticagrelor and prasugrel), East Asian patients have shown less favorable net clinical benefits compared with Caucasian patients, which may be related to differences in pharmacokinetic/pharmacodynamic profiles and therapeutic zone of antiplatelet effect. This updated consensus mainly focuses on state-of-the-art and current controversies in the East Asian population. In addition, when East Asian patients are administered potent P2Y₁₂ receptor inhibitors, the strategies and ongoing trials to overcome the related hurdles are discussed.

Systematic review with meta-analysis: the risk of gastrointestinal bleeding in patients taking third-generation P2Y12 inhibitors compared with clopidogrel

BACKGROUND

Ticagrelor and prasugrel are third-generation oral P2Y₁₂ receptor antagonists with rapid onset and pronounced platelet inhibition. However, higher overall bleeding rates have been reported for these agents when compared with clopidogrel.

AIM

To compare the risk of gastrointestinal bleeding (GIB) among users of third-generation P2Y₁₂ inhibitors with clopidogrel.

METHODS

We systematically searched for published randomised controlled trials of ticagrelor or prasugrel versus clopidogrel until September 2018. The primary outcome was the risk of GIB among users of third-generation P2Y₁₂ inhibitors when compared to clopidogrel, expressed as risk ratio (RR) and 95% confidence interval (CI). The rates of non-coronary artery bypass graft (CABG) major bleeding, life-threatening bleeding, fatal bleeding, and intracranial bleeding were analysed as secondary outcomes.

RESULTS

Forty-one studies were included in the analysis of non-CABG major bleeding, of which 12 were included in the analysis of GIB including 58 678 patients. Third-generation P2Y₁₂ inhibitors were associated with higher risk of GIB as compared with clopidogrel (RR 1.28, 95% CI 1.13-1.46). The findings were consistent for upper (RR 1.32, 95% CI 1.05-1.67) and unspecified GIB (RR 1.25, 95% CI 1.01-1.53), but not lower GIB (RR 1.25, 95% CI 0.95-1.65). Subgroup analysis showed higher GIB risk in prasugrel studies (RR 1.40, 95% CI 1.10-1.77) than in ticagrelor studies (RR 1.15, 95% CI 0.94-1.39). Third-generation P2Y₁₂ inhibitors also increased the risk of non-CABG major bleeding (RR 1.18, 95% CI 1.08-1.28).

CONCLUSION

Third-generation P2Y₁₂ inhibitors were associated with increased risk of GIB and non-CABG major bleeding when compared with clopidogrel.

Ticagrelor versus clopidogrel in East Asian patients with acute coronary syndrome: Systematic review and meta-analysis

BACKGROUND

Bleeding complications are associated with unfavorable outcomes in patients with acute coronary syndrome (ACS). Compared to Whites, several studies demonstrated a higher risk of bleeding in Asians who present with acute myocardial infarction. To date, the efficacy and safety of ticagrelor in East Asian population have not been well established.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials that compared ticagrelor and clopidogrel in East Asian patients with acute coronary syndrome (ACS). We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrial.gov database.

RESULTS

Three randomized controlled trials, including a total of 1552 patients, met our inclusion criteria. Study countries included Japan, South Korea, and China. All studies defined primary efficacy endpoint and major bleeding events in accordance with the PLATO definition. Ticagrelor was associated with a numerically lower, albeit statistically nonsignificant, risk of primary efficacy endpoint defined as a composite of death from vascular causes, myocardial infarction, or stroke (odds ratio 0.84; 95% confidence interval 0.43-1.63; p = 0.60). Ticagrelor was associated with a significantly higher risk of PLATO-defined major bleeding compared to clopidogrel (odds ratio 1.52; 95% confidence interval 1.04-2.23; p = 0.03).

CONCLUSIONS

Our meta-analysis demonstrated that ticagrelor was associated with a higher risk of major bleeding compared to clopidogrel in East Asian patients with ACS. Further studies evaluating the role of ticagrelor in management of ACS in East Asian patients are warranted.