Letter by Kim et al Regarding Article, "Clinically Significant Bleeding With Ticagrelor Versus Clopidogrel in Korean Patients With Acute Coronary Syndromes Intended for Invasive Management: A Randomized Clinical Trial".

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HomeCirculationVol. 141, No. 14Letter by Kim et al Regarding Article, “Clinically Significant Bleeding With Ticagrelor Versus Clopidogrel in Korean Patients With Acute Coronary Syndromes Intended for Invasive Management: A Randomized Clinical Trial” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Kim et al Regarding Article, “Clinically Significant Bleeding With Ticagrelor Versus Clopidogrel in Korean Patients With Acute Coronary Syndromes Intended for Invasive Management: A Randomized Clinical Trial” Yongcheol Kim, MD, Thomas W. Johnson, MBBS, MD and Myung Ho Jeong, MD, PhD Yongcheol KimYongcheol Kim https://orcid.org/0000-0001-5568-4161 Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Korea (Y.K.). Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (Y.K., M.H.J.). Search for more papers by this author , Thomas W. JohnsonThomas W. Johnson Department of Cardiology, Bristol Heart Institute, United Kingdom (T.W.J.). Search for more papers by this author and Myung Ho JeongMyung Ho Jeong Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (Y.K., M.H.J.). Search for more papers by this author Originally published6 Apr 2020https://doi.org/10.1161/CIRCULATIONAHA.119.044256Circulation. 2020;141:e737–e738To the Editor:We read with interest the recently published article by Park et al1 evaluating the comparison of clinical safety and efficacy between ticagrelor and clopidogrel in Korean patients with acute coronary syndrome. It is evident that the use of standard-dose ticagrelor is associated with a higher incidence of clinically significant bleeding complications, without a reduction in the incidence of ischemic events, in comparison with clopidogrel use at a 12-month end point. After reading this article carefully, we have some comments for the kind consideration of the authors.The authors acknowledge that preloading with antiplatelet therapy is supported by guidelines; however, it has been shown that this can be associated with an increased risk of bleeding, most commonly related to access site.2 Femoral access was frequently adopted (47.5% of the cohort), so it is not surprising that procedure-related bleeding contributed to 27.3% (18/66) of all clinically significant bleeds. Furthermore, contemporary guidance provides a class 1 level B recommendation for the use of proton pump inhibitors, but the use of proton pump inhibitors was very limited in the current study (2.5%). It is likely that the risk of gastrointestinal bleeding could have been minimized by the combined use of proton pump inhibitors with dual antiplatelet therapy.Enrollment of 800 patients from 10 major centers over 3 years suggests significant selection bias that was not addressed in the discussion. Application of these results to an unselected population must be undertaken with caution. The efficacy and safety of P2Y12 inhibitors in Korean patients presenting with acute myocardial infarction have been tested previously with the use of standard-dose ticagrelor (180 mg loading dose, 90 mg twice daily) and prasugrel (60 mg loading dose, 10 mg/d). Consistent with the findings in this contemporary study, use of potent P2Y12 inhibitors was associated with a significantly higher incidence of bleeding events without a reduction of ischemic events in comparison with clopidogrel.3 In a European population, downtitration of potent P2Y12 inhibition at one month resulted in an important reduction in bleeding.4 However, a landmark analysis of the current cohort at 30 days highlights that the difference in bleeding is observed early. Recent data from Japan5 have highlighted the effective use of reduced-dose potent P2Y12 inhibitors (3.75 mg prasugrel once daily) in a heterogeneous population of stable patients and patients with acute coronary syndrome. Large-scale studies in East Asian populations clearly are required to establish the appropriate dosing, duration of treatment, and possible deescalation of potent P2Y12 inhibition.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circ