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45. Clopidogrel versus ticagrelor in high-bleeding risk patients presenting with acute coronary syndromes. insights from the multicenter START-ANTIPLATELET registry

Author

Gragnano F., Moscarella E., Calabro P., Cesaro A., Pafundi P. C., Ielasi A., Patti G., Cavallari I., Antonucci E., Cirillo P., Pignatelli P., Palareti G., Pelliccia F., Gaudio C., Sasso F. C., Pengo V., Gresele P., Marcucci R., Fimiani F., Vitale R. A., Schiavo A., Conte M., Di Maio D., Pastori D., Menichelli D., Grossi G., Di Serafino L., Taglialatela V., Galiero R., Acierno C., del Pinto M., Gugliemini G., Gragnano, F., Moscarella, E., Calabro, P., Cesaro, A., Pafundi, P. C., Ielasi, A., Patti, G., Cavallari, I., Antonucci, E., Cirillo, P., Pignatelli, P., Palareti, G., Pelliccia, F., Gaudio, C., Sasso, F. C., Pengo, V., Gresele, P., Marcucci, R., Fimiani, F., Vitale, R. A., Schiavo, A., Conte, M., Di Maio, D., Pastori, D., Menichelli, D., Grossi, G., Di Serafino, L., Taglialatela, V., Galiero, R., Acierno, C., del Pinto, M., Gugliemini, G., Calabrò, Paolo., and START-ANTIPLATELET, Collaborators

Subjects
Registrie, Male, Risk, medicine.medical_specialty, Acute coronary syndrome, animal structures, medicine.medical_treatment, Hemorrhage, 030204 cardiovascular system & hematology, ticagrelor, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Cause of Death, Internal Medicine, medicine, Clinical endpoint, Humans, 030212 general & internal medicine, Myocardial infarction, cardiovascular diseases, Prospective Studies, Registries, Acute Coronary Syndrome, bleeding, clopidogrel, dual antiplatelet therapy, percutaneous coronary intervention, Stroke, Aged, Aged, 80 and over, business.industry, Platelet Aggregation Inhibitor, Hazard ratio, Percutaneous coronary intervention, medicine.disease, Clopidogrel, Prospective Studie, Italy, Emergency Medicine, Cardiology, Female, business, Ticagrelor, Platelet Aggregation Inhibitors, medicine.drug, Human
Abstract

Optimal dual antiplatelet therapy (DAPT) strategy in high-bleeding risk (HBR) patients presenting with acute coronary syndrome remains debated. We sought to investigate the use of clopidogrel versus ticagrelor in HBR patients with acute coronary syndrome and their impact on ischemic and bleeding events at 1year. In the START-ANTIPLATELET registry (NCT02219984), consecutive patients with ≥ 1 HBR criteria were stratified by DAPT type in clopidogrel versus ticagrelor groups. The primary endpoint was net adverse clinical endpoints (NACE), defined as a composite of all-cause death, myocardial infarction, stroke, and major bleeding. Of 1209 patients with 1-year follow-up, 553 were defined at HBR, of whom 383 were considered eligible for the study as on DAPT with clopidogrel (174 or 45.4%) or ticagrelor (209 or 54.6%). Clopidogrel was more often administered in patients at increased ischemic and bleeding risk, while ticagrelor in those undergoing percutaneous coronary intervention. Mean DAPT duration was longer in the ticagrelor group. At 1year, after multivariate adjustment, no difference in NACEs was observed between patients on clopidogrel versus ticagrelor (19% vs. 11%, adjusted hazard ratio 1.27 [95% CI 0.71–2.27], p = 0.429). Age, number of HBR criteria, and mean DAPT duration were independent predictors of NACEs. In a real-world registry of patients with acute coronary syndrome, 45% were at HBR and frequently treated with clopidogrel. After adjustment for potential confounders, the duration of DAPT, but not DAPT type (stratified by clopidogrel vs. ticagrelor), was associated with the risk of ischemic and bleeding events at 1year.

Published
2021

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