Ticagrelor may not be superior to twice-daily clopidogrel in ST-segment elevation myocardial infarction following percutaneous coronary intervention

1. At one month, ticagrelor was not superior to twice-daily clopidogrel in reducing major adverse cardiovascular events (MACEs) in adult patients receiving primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI).

Evidence Rating Level: 1 (Excellent)

The highest risk period for MACEs after primary PCI for STEMI is in the first month. Both ticagrelor and double-dose clopidogrel have been shown to improve patient outcomes after acute coronary syndrome. However, no study has compared these strategies in the early high-risk post-STEMI period. This double-blind, randomized controlled trial analyzed whether ticagrelor is superior to twice-daily clopidogrel in reducing 30-day MACEs in adult patients with STEMI undergoing primary PCI. 2,201 patients (mean[SD] age, 54.8 ± 10.1 years; 87.3% male) to receive either clopidogrel 75 mg twice daily or ticagrelor 90 mg twice daily for one month. All patients received aspirin 75 mg daily. At 7 and 14 days, there was a significantly lower incidence of MACEs in patients receiving ticagrelor ((HR: 0.15; 95% CI: 0.04-0.5; P = 0.002) and (HR: 0.46; 95% CI: 0.23-0.91; P = 0.02), respectively), although these differences were no longer statistically significant at 30 days (HR: 0.75; 95% CI: 0.44-1.27; P = 0.28; absolute risk difference: -0.7%; 95% CI: -2.05 to 0.60). The ticagrelor group had a higher risk of any bleeding event (HR: 2.08; 95% CI: 1.10-3.93), as defined by the Bleeding Academic Research Consortium (BARC) criteria, but there was no significant difference in the incidence of clinically significant or major bleeding (BARC 2, 3, 5; HR: 1.50; 95% CI: 0.42-5.31). Overall, ticagrelor was not superior to twice-daily clopidogrel in reducing MACEs at 1 month after primary PCI. However, further studies with larger cohorts are warranted as MACEs were significantly reduced in patients receiving ticagrelor at 7 and 14 days.

Click here to read this study in The Journal of the American College of Cardiology

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