Low-dose and standard-dose ticagrelor compared with clopidogrel in patients with acute coronary syndromes: A cohort study from china

Lower Ticagrelor Dosing in the Dual Antiplatelet Regimen for Neurointerventional Procedures

BACKGROUND

Ticagrelor, a P2Y12 inhibitor, offers a rapid onset and consistent platelet inhibition, making it a viable alternative for dual antiplatelet therapy (DAPT). The optimal ticagrelor dose for neurointerventional procedures, however, remains unclear. We report our experience with ticagrelor 60 mg twice daily plus aspirin 81 mg daily compared with the standard aspirin and clopidogrel regimen for intracranial stenting.

METHODS

We conducted a retrospective analysis of a prospectively maintained database, identifying consecutive patients who underwent intracranial stenting for aneurysm treatment or intracranial atherosclerosis. Patients received either ticagrelor 60 mg with aspirin or aspirin with clopidogrel 75 mg daily. Primary outcomes included peri-procedural ischemic and/or hemorrhagic events within 30 days. Secondary outcomes were the median P2Y12 reaction unit and in-stent stenosis rates at 6-month follow-up.

RESULTS

Among 119 patients, 59 received ticagrelor and 60 (50.4%) received clopidogrel. Baseline characteristics including age and gender were comparable between the two groups, although the ticagrelor group had a higher proportion of African-American patients. The majority of patients underwent aneurysm treatment (n=105; 88.23%), while the remainder received stenting for intracranial atherosclerosis (n=14; 11.77%). No ischemic events occurred in either group and intracranial hemorrhage rates were comparable (1.7% in both groups). The median P2Y12 reaction unit was significantly lower in the ticagrelor group (69 vs 126, P<0.001). In-stent stenosis rates were lower with ticagrelor (5% vs 21%).

CONCLUSION

Ticagrelor 60 mg for DAPT in intracranial stenting is safe and effective. Larger prospective studies may be required to validate these findings.

Low-dose prasugrel versus standard-dose ticagrelor in east Asian patients with acute coronary syndrome

Low-dose prasugrel demonstrated a similar effectiveness profile to clopidogrel in East Asian ACS patients, but its comparison with another new-generation potent P2Y12 inhibitor, ticagrelor, remains unclear. To compare the effectiveness and safety of low-dose prasugrel against those of standard-dose ticagrelor in East Asian patients with ACS. This retrospective cohort study used Taiwan's National Health and Welfare Database. This study included ACS patients who underwent percutaneous coronary intervention and, at discharge between January 1, 2018 and December 31, 2020, were prescribed with low-dose prasugrel plus aspirin or standard-dose ticagrelor plus aspirin. Stabilized inverse probability of treatment weighting was used to balance the covariates across these two groups. The primary effectiveness outcome was a composite of acute myocardial infarction, ischemic stroke, and cardiovascular death; the secondary effectiveness outcome was each of the individual components of the primary outcome, transient ischemic attack, and repeat revascularization. The primary safety outcome was a composite of intracranial hemorrhage and gastrointestinal bleeding, and the two secondary safety outcomes were intracranial hemorrhage and gastrointestinal bleeding. A total of 24,807 patients were included in this study. Among them, 1,493 were low-dose prasugrel users and 23,314 were standard-dose ticagrelor users. No significant differences were found in primary effectiveness [HR: 0.97 (0.74-1.28)] or primary safety outcomes [HR: 1.22 (0.73-2.01)] between the two study groups. For East Asian patients with ACS, low-dose prasugrel provides comparable effectiveness without increasing bleeding risk compared to standard-dose ticagrelor. Low-dose prasugrel may be an appropriate alternative for East Asian populations.

Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in East-Asian Patients with Acute Coronary Syndrome: Large Cohort Study

AIM

A high risk of bleeding is observed in East Asian patients with acute coronary syndrome (ACS). Therefore, the choice between two antiplatelet therapy drugs, ticagrelor and clopidogrel, remains controversial in this population with ACS. This study aimed to use a large cohort database to assess the clinical outcomes of ticagrelor and clopidogrel therapy, including major bleeding, recurrent ACS, and mortality, in this population.

METHODS

Between January 2009 and December 2019, 43,696 patients were diagnosed with ACS based on the medical history (International Classification of Diseases [ICD] code) of the Chang Gung Research Database. After excluding patients without percutaneous coronary intervention, with concurrent medical problems, and on non-standard dual antiplatelet therapy (DAPT) or a single antiplatelet agent, 18,046 patients were recruited for analysis. Ticagrelor- and clopidogrel-based DAPT were administered to 3666 patients and 14,380 patients, respectively. Baseline characteristics and clinical outcomes were compared between the two groups. A total of 4225 patients were defined as a high-bleeding-risk subgroup according to Academic Research Consortium for High Bleeding Risk (ARC-HBR) score (met one major or two minor criteria), of which 466 and 3759 patients received ticagrelor- and clopidogrel-based DAPT, respectively.

RESULTS

Before propensity score matching (PSM), younger age, higher prevalence of male sex, and higher body mass index were noted in the ticagrelor-based DAPT group in the whole cohort and high-bleeding-risk subgroup. After PSM, no difference in baseline characteristics and comorbidities between ticagrelor-based and clopidogrel-based DAPT groups in the whole cohort and high-bleeding-risk subgroup was noted. The Kaplan-Meier curves of recurrent ACS and major bleeding were significantly lower in the ticagrelor-based DAPT group than in the clopidogrel-based DAPT group, and that of cardiovascular (CV) and all-cause mortality showed no significant differences. After PSM, in the high-bleeding-risk subgroup, the Kaplan-Meier curve of recurrent ACS was significantly lower in the ticagrelor-based DAPT group than in the clopidogrel-based DAPT group, and that of major bleeding, CV, and all-cause mortality showed no significant differences.

CONCLUSION

In this large cohort study, patients receiving ticagrelor-based DAPT were at lower risk of recurrent ACS compared to those receiving clopidogrel-based DAPT, especially in the patients with myocardial infarction. Ticagrelor-based DAPT did not result in a higher risk of major bleeding in the whole ACS population and high-bleeding-risk subgroup. The rate of CV and all-cause mortality were similar between both the groups.