Is clopidogrel better than ticagrelor in reducing bleeding in stabilized patients with myocardial infarction undergoing percutaneous coronary intervention ?

This study investigated if de-escalation (reducing the intensity) of dual antiplatelet therapy (DAPT) with clopidogrel (Plavix) might be better than ticagrelor (Brilique)-based antiplatelet therapy in stabilized patients with acute myocardial infarction (MI; heart attack) undergoing percutaneous coronary intervention (PCI). The data showed that a de-escalation strategy with clopidogrel plus aspirin significantly reduced the risk of bleeding events compared to ticagrelor plus aspirin in these patients.

Coronary artery disease (CAD) is a condition in which the blood vessels in the heart become blocked. CAD can lead to acute myocardial infarction (MI), also known as a heart attack. Percutaneous coronary intervention (PCI) is a minimally-invasive surgical procedure to improve blood flow. During PCI the blockage in the artery is removed. In some cases, a stent may be inserted to keep a blood vessel open.

One risk with PCI is that blood clots can form on the stent and cause a blockage. Platelets are cells in the blood that cause clotting. Dual antiplatelet therapy (DAPT) is used to reduce this risk. DAPT reduces the risk of clotting and further blockages after PCI. Acetylsalicylic acid (Aspirin) and ticagrelor are antiplatelet medications commonly used in DAPT. Another common DAPT combination is aspirin and clopidogrel.

Previous studies have shown that long-term ticagrelor treatment can reduce the risk of heart attack, however, it is associated with an increased risk of bleeding compared to clopidogrel in patients with MI who have had PCI treatment. Therefore, it is unknown if de-escalation (reducing the intensity of DAPT) with clopidogrel might be better than ticagrelor-based antiplatelet therapy in stabilized patients with MI undergoing PCI.

This study involved 2697 patients with MI undergoing PCI. Patients were randomly assigned into 2 groups after 1 month of ticagrelor plus aspirin DAPT. Group 1 included 1349 patients who received clopidogrel plus aspirin. Group 2 included 1348 patients who continued to receive ticagrelor plus aspirin. The patients were followed up for 12 months.

After 12 months, heart attacks, stroke, death, and bleeding events occurred in 4.6% of the patients in group 1 compared to 8.2% of the patients in group 2. This difference was statistically significant.

There was no significant difference in heart attacks, stroke, or death events between group 1 (2·1%) and group 2 (3·1%).

Bleeding occurred in 3% of the patients in group 1 compared to 5.6% of the patients in group 2. This difference was significant. Clopidogrel plus aspirin reduced the risk of bleeding by 48% compared to ticagrelor plus aspirin.

This study concluded that a de-escalation strategy with clopidogrel plus aspirin significantly reduced the risk of bleeding events compared to ticagrelor plus aspirin in stabilized patients with MI undergoing PCI.

This study was funded by ChongKunDang Pharm, Medtronic, Abbott, and Boston Scientific. This study only included patients from South Korea. The patients knew which treatment they were getting. This might have influenced the results.