Abstract
Objectives The objective of this registry was to study the safety of prehospital initiation of ticagrelor compared with clopidogrel. Background Ticagrelor has replaced clopidogrel in many hospitals as the routinely used antiplatelet drug in patients with ST-segment elevation myocardial infarction (STEMI). Nevertheless, in the PLATelet inhibition and patient Outcomes (PLATO) trial, ticagrelor was associated with an increase in non-CABG (non–coronary artery bypass grafting)-related major bleeding. Data comparing the safety of ticagrelor and clopidogrel after prehospital initiation of treatment are not available. Methods A retrospective, multicenter registry was performed. Selection criteria were the administration of a prehospital loading dose of ticagrelor or clopidogrel according to the ambulance STEMI treatment protocol and the presentation to a percutaneous coronary intervention–capable hospital in our region between January 2011 and December 2012. Follow-up was performed using the electronic patient files for the time period between the antiplatelet loading dose and hospital discharge. The data were analyzed using a primary bleeding end point (any bleeding) and a secondary thrombotic end point (all-cause mortality, spontaneous myocardial infarction, definite stent thrombosis, stroke, or transient ischemic attack). Results Data of 304 clopidogrel-treated and 309 ticagrelor-treated patients were available for analysis. No significant difference in bleeding rate was observed between both groups, using univariate (17.8 vs. 20.1%; p = 0.47; odds ratio, 1.16 [95% confidence interval, 0.78–1.74]) and multivariate ( p = 0.42) analysis. Also for the secondary thrombotic end point (6.3 vs. 4.9%, p = 0.45), no significant differences were observed. Conclusion In this real-world registry, no significant differences in bleeding or thrombotic event rate were found between ticagrelor and clopidogrel after prehospital initiation of treatment.
Highlights
The early use of Dual antiplatelet therapy (DAPT) in segment elevation myocardial infarction (STEMI) patients prevents the occurrence of stent thrombosis, which is relevant because stent thrombosis is associated with a high mortality rate.[7,8,9]
An observational study performed by De Backer et al in 3,497 STEMI patients, found no benefit of prasugrel or ticagrelor compared with clopidogrel on early coronary reperfusion (TIMI 3 flow in the infarct-related artery) or 30 days major adverse cardiovascular events (MACE), this strategy seemed to be safe without increase in major bleeding.[33]
Our analysis has a comparable design to the study performed by De Backer et al Most important differences are the selection of patients, the time since the administration of the antiplatelet loading dose (36 minutes to hospital arrival vs. $65–75 minutes to angiography), and sample size (304 clopidogrel-treated and 309 ticagrelor-treated patients vs. 1,532 clopidogrel-treated and 491 ticagrelor-treated patients)
Summary
Dual antiplatelet therapy (DAPT) plays a major role in the acute treatment of ST-segment elevation myocardial infarction (STEMI), as the process of thrombus formation during STEMI is strongly platelet driven.[1,2,3] DAPT reduces the number of atherothrombotic events in patients with acute myocardial infarction and in patients undergoing percutaneous coronary intervention (PCI).[3,4,5,6] The early use of DAPT in STEMI patients prevents the occurrence of stent thrombosis, which is relevant because stent thrombosis is associated with a high mortality rate.[7,8,9] The current STEMI guidelines recommend the early administration of DAPT, as soon as the STEMI diagnosis is established.[10,11]Until a few years ago, the cyclooxygenase (COX)-1 inhibitor aspirin and the adenosine diphosphate (ADP) receptor antagonist clopidogrel were the treatment of choice. The available data describing the bleeding risk are limited, because most anticoagulants were only tested in combination with clopidogrel.[12,13,21,22] the STEMI diagnosis made in the ambulance is correct in the large majority of patients, some patients will be misdiagnosed and treated with antiplatelet treatment in the absence of a myocardial infarction. Conclusion In this real-world registry, no significant differences in bleeding or thrombotic event rate were found between ticagrelor and clopidogrel after prehospital initiation of treatment
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