Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in Acute Coronary Syndrome: A Comprehensive Meta-Analysis

Abstract

BackgroundTicagrelor is currently recommended for patients with the acute coronary syndrome (ACS). However, recent studies have yielded controversial results.ObjectiveTo compare the clinical outcomes between ticagrelor and clopidogrel in patients with ACS.MethodsThree electronic databases were queried until April 25, 2021. We defined major adverse cardiovascular events (MACEs) as the primary efficacy endpoint. The secondary efficacy endpoints included stroke, stent thrombosis, cardiovascular death, all-cause death, and myocardial infarction. The safety endpoints were (major and minor) bleeding. Odds ratios (ORs) and 95% CIs were calculated to represent the estimated effect sizes.ResultsA total of 270,937 patients with ACS from 10 clinical trials and 18 observational studies were included. No significant difference was detected in MACE (OR 0.81, 95% CI 0.60–1.08, p = 0.15, I2 = 64.83%). However, ticagrelor introduced a higher risk of bleeding (1.46, 1.17–1.83, 0.00, 61.66%) and minor bleeding (1.71, 1.33–2.21, 0.00, 4.65%) in clinical trials. The results of secondary efficacy endpoints differed in the clinical trials and observational studies. Subgroup analysis demonstrated that ticagrelor showed better therapeutic effects in patients who underwent the percutaneous coronary intervention (PCI) (0.38, 0.23–0.63, 0.00, 0) than those intended for PCI (1.03, 0.76–1.38, 0.87, 64.26%). Meanwhile, ticagrelor showed different therapeutic effects on patients with ACS of different ethnicities and different countries.ConclusionThis meta-analysis demonstrated that ticagrelor is not superior to clopidogrel in MACE but is associated with a higher risk of bleeding in patients with ACS. Different PCI strategies, ethnicities, and countries may be the factors that contribute to different therapeutic effects of ticagrelor.Systematic Review RegistrationThis study is registered with PROSPERO (CRD42021251212).

A Comparison of the Effects of Ticagrelor and Clopidogrel in Patients with Acute ST-Segment Elevation Myocardial Infarction: A systematic review and Meta-analysis

“…Findings in the present study resulted in a decrease in the MACE, although this decrease was not statistically signi cant. A meta-analysis that included studies with ACS patients did not prove the superiority of Ticagrelor over Clopidogrel in this outcome (53). This is notable that since there is a possibility of bleeding and upper gastrointestinal complications in patients who receive the combination of Clopidogrel and Aspirin, these patients are prescribed drugs such as proton-pump inhibitors such as pantoprazole, which reduces the risk of bleeding by protecting the digestive tract mucosa, simultaneously (54).…”

Efficacy and safety of clopidogrel versus ticagrelor for stabilized patients with acute coronary syndromes after percutaneous coronary intervention: results from a real-world registry in China

“…Recent studies have shown that ticagrelor is associated with a significantly higher risk of dyspnea, major bleeding, and bradycardia events than clopidogrel. [16][17][18][19][20] And the compliance with ticagrelor in patients has also been shown to be lower than that with clopidogrel, which also brought challenges to the long-term treatment of ticagrelor.…”

Current views on antiplatelet therapy in acute coronary syndrome patients: the place of clopidogrel

“…Многочисленные исследования реальной клинической практики демонстрируют весьма противоречивые результаты в отношении сравнительной эффективности и безопасности клопидогрела и более мощных блокаторов рецепторов P2Y12 [8,9]. Часть из них не подтверждает преимуществ тикагрелора и прасугрела в отношении ишемических событий в рутинной практике.…”

“…Поскольку клопидогрел последовательно демонстрировал наиболее благоприятный профиль безопасности из всех блокаторов рецепторов P2Y12 в рандомизированных исследованиях, метаанализах [26] и исследованиях реальной клинической практики [28], именно этот препарат рекомендуют выбирать эксперты Европейского общества кардиологов (ЕОК) у пациентов с ОКС без подъема сегмента ST и высоким риском кровотечений [15]. В рекомендациях 2020 г. предложен четкий алгоритм выбора режима антиагрегантной терапии в зависимости от риска кровотечений.…”