Ticagrelor versus clopidogrel for complex percutaneous coronary intervention in chronic coronary syndrome: a post-hoc analysis of the ALPHEUS study

Abstract

Abstract Background Whether ticagrelor utilization in chronic coronary syndrome patients undergoing complex percutaneous coronary intervention (PCI) could prevent type 4 myocardial infarction (MI) or myocardial injury as compared to clopidogrel is unknown. Purposes To evaluate the frequency and outcomes of complex PCI in stable coronary patients and the efficacy of ticagrelor versus clopidogrel in these patients randomized in the ALPHEUS trial. Methods All PCI procedures were blindly reviewed by two core laboratory readers and classified as complex if they had at least one of the following criteria: stent length ≥60 mm, two-stent bifurcation, use of atherectomy, left main, bypass graft, chronic total occlusion, use of guide catheter extensions, multiwire technique, multiple stents. The primary endpoint was a composite of type 4a or b MI and major myocardial injury, defined by the 3rd and 4th universal definition of MI, during the 48h after PCI. Angiographic complications and the composite of death, MI, stroke at 48 hours and at 30 days were also evaluated. We compared the event rates in the randomized groups according to the presence or not of complex PCI criteria and evaluated the interaction with the randomization to ticagrelor or clopidogrel. Results Among the 1866 patients randomized, 910 (48.3%) PCI were classified as complex PCI and 956 (51.7%) as not complex. Multiple criteria of complex PCI were found in 14.4% (2 criteria) and 9.1% (≥3 criteria) of the patients. The primary endpoint was more frequent in complex PCI than in the not-complex PCI (45.6% vs 26.6%; p<0.001) driven by higher rates of type 4MI and angiographic complications (12.2% vs 4.8 %; p<0.001 and 19.3% vs 8.6%; p<0.05, respectively). The composite of death, MI, stroke at 48 hours (12.7% vs 5.1 %; p<0.05) and at 30 days (13.4% vs 5.3%; p<0.05) were also more frequent in complex PCI. No interaction was found between the complexity of PCI and the randomized treatment for the primary endpoint (p for interaction = 0.35) nor the secondary endpoints. Conclusions Complex PCI patients have higher rates of periprocedural and cardiovascular events which are not reduced by ticagrelor as compared with clopidogrel.