Abstract 150: Early Administration of Ticagrelor in Patients with Non-ST Segment Elevation Myocardial Infarction is Associated with Improved Survival

Abstract

Background: Dual antiplatelet therapy (aspirin plus clopidogrel/ticagrelor - DAPT) is a mainstay treatment for NSTEMI. However, studies suggest that early administration of clopidogrel may not confer significant benefit over later administration. As the time to peak plasma concentration is much shorter for ticagrelor (1-2 hours) vs. clopidogrel (8-12 hours), we hypothesized that earlier administration of ticagrelor may confer survival benefit over later administration. Methods: Patients treated for NSTEMI at our center using DAPT, January 2012 through May 2017, between 18 and 90 years old, were retrospectively identified. Patients who left the hospital against medical advice, were discharged to hospice, or were already treated with DAPT or an anticoagulant at the time of presentation were excluded. Patients who received ticagrelor ≤ 2 hours from arrival were matched with similar patients who received ticagrelor > 2 hours from arrival using 30 clinical and demographic variables. Patients who received clopidogrel were matched similarly. We then compared survival for 500 days using a log rank test. Results: 349 patients met the inclusion criteria. Of these, 18 received ticagrelor within 2 hours and 41 received clopidogrel within 2 hours. These were matched with 18 and 41 control patients, respectively, who received ticagrelor/clopidogrel > 2 hours from arrival. As shown in Figure 1a, patients who received ticagrelor ≤ 2 hours from arrival had significantly lower 500-day mortality than patients who received ticagrelor > 2 hours from arrival (0.0% vs. 27.7%; p=0.017). There was no difference in mortality between the early and late clopidogrel groups (Figure 1b). Conclusion: In the ticagrelor era, early administration of DAPT with ticagrelor (within 2 hours of arrival) may be associated with improved mortality in patients with NSTEMI, an effect not seen with clopidogrel. Larger studies investigating the impact of door to DAPT time in patients with NSTEMI are needed.