Comparative Effectiveness of Oral Antiplatelet Agents in Patients with Acute Coronary Syndrome

Abstract

OBJECTIVE In randomized controlled trials, prasugrel and ticagrelor reduced cardiovascular complications in patients with acute coronary syndrome (ACS) compared with clopidogrel. However, limited head-to-head comparisons have been conducted across the three antiplatelet agents using real-world data. The aim of this study was to compare clinical outcomes of three strategies during a 1-year period after percutaneous coronary intervention (PCI). METHODS Rates of all-cause and acute myocardial infarction (AMI) hospitalizations were compared retrospectively using an insurance claims database. Patients who filled a prescription for an oral antiplatelet agent between September 2011 and December 2013 for post ACS-PCI care were identified. Time to allcause and AMI hospitalization for a 365-day postdischarge period was compared using Cox proportional hazard models controlling for potential confounders within a propensity score matched cohort. RESULTS A matched cohort of 9504 clopidogrel, 7128 prasugrel, and 2376 ticagrelor patients was analyzed. The 1-year hazard ratio (HR) for the two newer agents versus clopidogrel was 0.84 (0.78-0.91). The HR for the newer agents versus clopidogrel of admission with AMI as the primary diagnosis was 0.78 (0.61-1.03), and for AMI as any diagnosis during a hospitalization was 0.88 (0.77-1.00). The HR of all-cause admission for ticagrelor versus prasugrel was 0.97 (0.84-1.13), and the HRs of AMI-related admission were not statistically significant between the two agents. Robustness checks across statistical methods to control for potential confounders did not influence the conclusion. CONCLUSION This real-world study demonstrated that use of the newer agents following PCI was associated with a decrease in all-cause and AMI-related hospitalizations. However, no significant difference was found in the rate of admission between ticagrelor versus prasugrel. Due to concerns regarding statistical power, future studies should examine larger cohorts to obtain more precise estimates for AMI hospitalization for ticagrelor and prasugrel.

Comparative effectiveness and safety of antiplatelet drugs in patients with diabetes mellitus and acute coronary syndrome

“…A retrospective cohort study based on TRUVEN MarketScan claims data that included all patients observed a decreased rate of all‐cause and MI‐related hospital admissions in patients using prasugrel or ticagrelor when compared to clopidogrel irrespective of treatment duration. No difference was noted between prasugrel and ticagrelor; however, the sample size for this comparison was limited (n = 2524 ticagrelor patients and n = 8335 prasugrel patients) …”

Loading doses of ticagrelor versus clopidogrel in preventing periprocedural myocardial infarction in Asian patients with acute coronary syndrome

“…11 Ticagrelor provides faster, greater, and more consistent P2Y12 inhibition and reduces more ischemic events in patients undergoing PCI as compared with clopidogrel. 12 PLATO (Study of Platelet Inhibition and Patient Outcomes), a multicenter, randomized, double-blind trial, aimed to determine the superiority of the ticagrelor over clopidogrel in the prevention of vascular events and death in 18,624 patients presenting with ACS. 13 The patients were randomized to receive either ticagrelor (180 mg loading, followed by 90 mg twice daily maintenance dose) or clopidogrel (300-600 mg loading, followed by 75 mg daily maintenance dose) group.…”

“…11 Ticagrelor provides faster, greater, and more consistent P2Y12 inhibition and reduces more ischemic events in patients undergoing PCI as compared with clopidogrel. 12…”

Antiplatelet Therapy Changes for Patients With Myocardial Infarction With Recurrent Ischemic Events: Insights Into Contemporary Practice From the TRANSLATE‐ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) Study

“…In addition, ticagrelor was released in the United States during the conduct of the TRANSLATE‐ACS study, and was used infrequently by patients enrolled in the study; only 2.1% of patients in the TRANSLATE‐ACS study were treated with ticagrelor at the time of their index event. Practice changes since the TRANSLATE‐ACS study period show a small, but significant, increase in uptake of higher‐potency P2Y 12 inhibitors in the United States, and these data may not fully reflect current practices; however, >50% of patients with ACS are still treated with clopidogrel in many contemporary US registries 8, 38, 39. Last, because patients in the TRANSLATE‐ACS study were only observed for 15 months after the index MI event, we are unable to report outcomes for patients with P2Y 12 inhibitor intensification in response to recurrent events compared with those without intensification.…”