Abstract
There are no randomised data on which antiplatelet agent to use in elderly patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and an indication for oral anticoagulation (OAC). The randomised POPular Age trial, in patients of 70 years or older with NSTE-ACS, showed a reduction in bleeding without increasing thrombotic events in patients using clopidogrel as compared to ticagrelor. In this sub-analysis of the POPular AGE trial, we compare clopidogrel with ticagrelor in patients with a need for oral anticoagulation. The follow-up duration was one year. The primary bleeding outcome was Platelet Inhibition and Patient Outcomes (PLATO) major and minor bleeding. The primary thrombotic outcome consisted of cardiovascular death, myocardial infarction and stroke. The primary net clinical benefit outcome was a composite of all-cause death, myocardial infarction, stroke, and PLATO major and minor bleeding. A total of 184/1011 (18.2%) patients on OAC were included in this subanalysis; 83 were randomized to clopidogrel and 101 to ticagrelor. The primary bleeding outcome was lower in the clopidogrel group (17/83, 20.9%) compared to the ticagrelor group (33/101, 33.5%; p = 0.051), as was the thrombotic outcome (7/83, 8.4% vs. 19/101, 19.2%; p = 0.035) and the primary net clinical benefit outcome (23/83, 27.7% vs. 49/101, 48.5%; p = 0.003). In this subgroup of patients using OAC, clopidogrel reduced PLATO major and minor bleeding compared to ticagrelor without increasing thrombotic risk. This analysis therefore suggests that, in line with the POPular Age trial, clopidogrel is a better option than ticagrelor in NSTE-ACS patients ≥70 years using OAC.
Highlights
For patients with an acute coronary syndrome (ACS), dual antiplatelet therapy (DAPT) is of utmost importance for the prevention of thrombo-embolic events
22.9% of patients randomised to clopidogrel and 20.8% randomised to ticagrelor were on triple therapy, consisting of aspirin + P2Y12 inhibitor + oral anticoagulation (OAC)
confidence intervals (CI): confidence interval; CV: cardiovascular; Hazard ratios (HR): hazard ratio; OAC: oral anticoagulation; PLATO; Platelet inhibition and patient outcomes. This sub-analysis of the POPular AGE trial of patients using OAC at discharge showed the following: (1) most (75%) of the patients randomised to ticagrelor had to discontinue ticagrelor or were switched to clopidogrel; (2) in line with the main results of the POPular AGE trial, in this subgroup, clopidogrel reduced PLATO major and minor bleeding compared to ticagrelor, not significantly; (3) clopidogrel was significantly better in terms of the net clinical benefit outcome compared to ticagrelor
Summary
For patients with an acute coronary syndrome (ACS), dual antiplatelet therapy (DAPT) is of utmost importance for the prevention of thrombo-embolic events. The antithrombotic treatment of these patients is more complicated when patients have an indication for oral anticoagulation (OAC), such as atrial fibrillation (AF), because the concomitant use of antiplatelet therapy and oral anticoagulation significantly increases the risk of bleeding [1]. This is especially an issue in elderly patients, as the prevalence of AF rapidly increases with age, and age itself is associated with bleeding [2,3]. In this pre-specified subgroup analysis of the POPular AGE trial we compare patients 70 years of age or older with non-ST-elevation ACS (NSTE-ACS) using oral anticoagulation, randomised to clopidogrel or ticagrelor
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Disclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.