Net Adverse Clinical Events in Patients Treated With Ticagrelor vs Clopidogrel After PCI for ACS

Man holds inscription Percutaneous coronary intervention pci in the hospital.
Ticagrelor and clopidogrel were found to be associated with comparable long-term net adverse clinical events among patients who underwent PCI for ACS.

Ticagrelor and clopidogrel were found to be associated with comparable long-term net adverse clinical events (NACE) among patients who underwent percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), according to a study published in JAMA.

In this retrospective cohort study, the data of adult patients (N=183,579; ages, ≥20 years) who had undergone PCI for ACS from electronic medical record databases from the United States (n=2) and South Korea (n=1) were examined. Patients who were prescribed ticagrelor (n=43,578) or clopidogrel (n=140,001) within 7 days of the procedural date were included. Patients were assessed for adverse events for up to 1 year following PCI.

The rate of patients in these cohorts who were prescribed ticagrelor increased over time, up to 32.0% in South Korea in 2016 and 43.0% in the United States in 2018. To balance the study population, a subset of 31,290 individuals from each prescription group were selected.

Risk for NACE did not differ between medications for 1 of the United States databases (hazard ratio [HR], 1.06; 95% CI, 0.90-1.24; P =.52) and in the South Korea data (HR, 1.02; 95% CI, 0.96-1.09; P =.50). In the second US database, the risk for NACE was found to be lower in patients prescribed  clopidogrel vs ticagrelor (14.6% vs 15.1%, respectively; HR, 1.08; 95% CI, 1.00-1.17; P =.05). This difference was no longer present in a pooled meta-analysis with propensity matched subgroups from all 3 databases (HR, 1.05; 95% CI, 1.00-1.10; P =.06), but was still present when data from the 2 US databases were considered (HR, 1.08; 95% CI, 1.00-1.16; P =.04).

At 1 year, patients treated with ticagrelor vs clopidogrel had comparable rates of: ischemic events (13.5% vs 13.4%, respectively; HR, 1.03; 95% CI, 0.98-1.08; P =.32), ischemic stroke (0.7% vs 0.8%, respectively; HR, 0.93; 95% CI, 0.76-1.13; P =.46), recurrent acute myocardial infarction (8.1% vs 8.2%, respectively; HR, 1.01; 95% CI, 0.94-1.08; P =.81), revascularization (4.3% vs 4.3%, respectively; HR, 1.08; 95% CI, 0.85-1.38; P =.51), and all-cause mortality (2.05% vs 2.1%, respectively; HR, 0.97; 95% CI, 0.81-1.16; P =.74).

Use of ticagrelor vs clopidogrel was associated with increased instances of dyspnea (27.3% vs 22.6%, respectively; HR, 1.21; 95% CI, 1.17-1.26; P <.001), hemorrhagic events (2.1% vs 1.6%, respectively; 95% CI, 1.13-1.61; P =.001), hemorrhagic stroke (0.3% vs 0.2%, respectively; HR, 1.60; 95% CI, 1.10-2.33; P =.01), and gastrointestinal bleeds (1.9% vs 1.4%, respectively; HR, 1.32; 95% CI, 1.05-1.66; P =.02).

These results may have been influenced by PCI procedures and unmeasured baseline characteristics, which were not included in this analysis.

The study authors concluded that overall, ticagrelor and clopidogrel recipients had similar risk for NACE and mortality at 1 year, however ticagrelor was associated with increased risk for hemorrhagic events.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


You S C, Rho Y, Bikdeli B, et al. Association of ticagrelor vs clopidogrel with net adverse clinical events in patients with acute coronary syndrome undergoing percutaneous coronary intervention. JAMA. 2020;324(16):1640-1650. doi:10.1001/jama.2020.16167