Acute coronary syndrome: efficacy and safety of P2Y12 inhibitors

  • Peyracchia M & al.
  • Am J Cardiovasc Drugs
  • 3 Oct 2019

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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Takeaway

  • Ticagrelor was more effective in reducing ischaemic events during the first year after acute coronary syndrome (ACS), but was associated with an increased risk for major bleedings.
  • Prasugrel demonstrated a better balance between ischaemic and bleeding recurrent events.

Why this matters

  • Real-life data comparing clopidogrel, prasugrel, and ticagrelor for unselected patients undergoing PCI for ACS are lacking.

Study design

  • Study included 19,825 patients with ACS who underwent PCI and were treated with DAPT (clopidogrel, 14,105; prasugrel, 2364; ticagrelor, 3356) using data from the RENAMI and BleeMACS registries.
  • Primary outcome: net adverse clinical events (NACEs; all-cause death, myocardial infarction [MI] and Bleeding Academic Research Consortium [BARC] 3-5 bleeding).
  • Secondary outcome: major adverse cardiovascular events (MACEs; death and MI).
  • Funding: None disclosed.

Key results

  • After propensity score matching at 1 year, prasugrel vs clopidogrel significantly reduced the incidence of NACEs (4.2% vs 7.6%; P=.002) and MACEs (2.6% vs 5.2%; P=.007).
  • Ticagrelor significantly reduced rates of MACEs vs clopidogrel (2.7% vs 6.2%; P<.001 but not naces vs p=".07).</li">
  • Ticagrelor was equally effective as prasugrel in reducing MACEs (2.8% vs 2.4%) with a trend towards a reduction in MI (0.2% vs 0.4%; P=.56 for both) but was associated with an increased risk for BARC 3-5 bleedings (3.8% vs 1.7%; P=.04).
  • In the daily risk analysis, clopidogrel demonstrated binomial distribution with a peak of ischaemic risk at 3 months, which decreased towards bleedings, prasugrel had a constant equivalence between opposite risks, and ticagrelor constantly reduced recurrent MI risk despite higher risk for BARC 3-5 events.

Limitations

  • Risk of unmeasured confounding.
  • Observational design.