Abstract 12895: Superior Effectiveness and Safety of Ticagrelor in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Nationwide Registry-Based Study

Abstract

Introduction: Dual antiplatelet therapy with aspirin and a P2Y 12 inhibitor is recommended following PCI for ACS. The optimal choice of P2Y 12 inhibitor remains debated. We compared effectiveness and safety of clopidogrel, ticagrelor, and prasugrel in a large, nationwide cohort of patients with ACS undergoing PCI. Methods: Registry-based study of first-time ACS patients who underwent PCI ≤7 days of admission and redeemed a prescription of a P2Y 12 inhibitor ≤30 days of the index event. The primary outcome was major adverse cardiovascular events (MACE): a composite of cardiovascular death, recurrent myocardial infarction, stroke, or repeat revascularization at 12 months. The safety outcome was bleeding requiring hospitalization at 12 months. Multivariable logistic regression with average treatment effect modeling was used to calculate standardized absolute and relative risks for outcomes across age, sex, comorbidity, bleeding, and concomitant anticoagulant therapy distributions. Results: We included 26,997 patients; 6,585 were discharged on clopidogrel, 18,425 on ticagrelor, and 1,987 on prasugrel. Corresponding median ages were 70, 64, and 59 years (p<0.001). Patients in the clopidogrel group were more likely to have had a prior bleeding episode (p<0.001). Adjusted relative risks of MACE were 0.80 for ticagrelor vs clopidogrel (p<0.001), 0.85 for prasugrel vs clopidogrel (p<0.001), and 1.05 for prasugrel vs ticagrelor (p=0.22). Adjusted relative risks of bleeding were 0.82 for ticagrelor vs clopidogrel (p=0.001), 1.07 for prasugrel vs clopidogrel (p=0.56), and 1.30 for prasugrel vs ticagrelor (p=0.03). While statistically significant, the absolute differences in risk of bleeding among groups were modest (Figure). Conclusion: Ticagrelor and prasugrel were associated with lower risk of MACE than clopidogrel but did not significantly differ from each other. Ticagrelor was associated with a lower risk of bleeding than both clopidogrel and prasugrel.