Ticagrelor for patients with acute coronary syndromes: PLATOnic affair or lasting SWEDEHEART?

Abstract

This editorial refers to ‘Outcomes in patients treated with ticagrelor or clopidogrel after acute myocardial infarction: experiences from SWEDEHEART registry’, by A. Sahlen et al. doi:10.1093/eurheartj/ehw284. For many years, a 12-month course of clopidogrel plus lifelong aspirin comprised the standard antiplatelet regimen in patients after an acute coronary syndrome (ACS). This recommendation originally stemmed from the randomized, placebo-controlled Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial, in which the use of clopidogrel significantly reduced the composite endpoint of cardiovascular death, myocardial infarction (MI), or stroke, at the cost of an increased risk of non-fatal major bleeding, in patients with non-ST-segment elevation ACS (NSTE-ACS).1 A prospectively designed substudy extended this benefit on ischaemic events to the subgroup of patients who underwent percutaneous coronary intervention (PCI).2 Theoretical limitations associated with the use of clopidogrel include its irreversible binding to the ADP P2Y12 receptor, the required hepatic transformation into the active metabolite, and variable platelet inhibition. Unlike clopidogrel, ticagrelor provides both reversible and more consistent ADP receptor inhibition, and there is no need for biotransformation as the active compound itself is ingested.3 Based on results from the Platelet Inhibition and Patient Outcomes (PLATO) study, contemporary European Society of Cardiology (ESC) guidelines clearly favour the use of ticagrelor over clopidogrel in patients with ACS (class I recommendation), regardless of whether an invasive strategy is used or not.4,5 The approach in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines is slightly more conservative, with the preference of ticagrelor over clopidogrel being ‘reasonable’ (class IIa recommendation).6,7 Nevertheless, because of issues of cost, familiarity, and bleeding concerns, use of clopidogrel still remains common worldwide. This issue of the journal features an elegant report by Sahlen et al . from the Swedish Web-system …