Comparison of Safety and Efficacy Between Clopidogrel and Ticagrelor in Elderly Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

Abstract

Background: Dual antiplatelet therapy combining aspirin with a P2Y12 adenosine diphosphate receptor inhibitor is a therapeutic mainstay for acute coronary syndrome (ACS). However, the optimal choice of P2Y12 adenosine diphosphate receptor inhibitor in elderly (aged ≥65 years) patients remains controversial. We conducted a meta-analysis to compare the efficacy and safety of ticagrelor and clopidogrel in elderly patients with ACS. Methods: We comprehensively searched in Web of Science, EMBASE, PubMed, and Cochrane databases through 29th March, 2021 for eligible randomized controlled trials (RCTs) comparing the efficacy and safety of ticagrelor or clopidogrel plus aspirin in elderly patients with ACS. Four studies were included in the final analysis. A fixed effects model or random effects model was applied to analyze risk ratios (RRs) and hazard ratios (HRs) across studies, and I2 to assess heterogeneity.Results: A total number of 4429 elderly patients with ACS were included in this analysis, of whom 2170 (49.0%) patients received aspirin plus ticagrelor and 2259 (51.0%) received aspirin plus clopidogrel. The ticagrelor group showed a significant advantage over the clopidogrel group concerning all-cause mortality (HR 0.78, 95% CI 0.63–0.96, I2 = 0%; RR 0.79, 95% CI 0.66–0.95, I2 = 0%) and cardiovascular death (HR 0.71, 95% CI 0.56–0.91, I2 = 0%; RR 0.76, 95% CI 0.62–0.94, I2 = 5%) but owned a higher risk of PLATO major or minor bleeding (HR 1.46, 95% CI 1.13–1.89, I2 = 0%; RR 1.40, 95% CI 1.11–1.76, I2 = 0%). Both the groups showed no significant difference regarding major adverse cardiovascular events (MACEs) (HR 1.06, 95% CI 0.68–1.65, I2 = 77%; RR 1.04, 95% CI 0.69–1.58, I2 = 77%).Conclusion: For elderly ACS patients, aspirin plus ticagrelor reduces cardiovascular death and all-cause mortality but increases the risk of bleeding. Herein, aspirin plus ticagrelor may extend lifetime for elderly ACS patients compared with aspirin plus clopidogrel. The optimal DAPT for elderly ACS patients may be a valuable direction for future research studies.

Optimal P2Y12 inhibitor durations in older men and older women following an acute myocardial infarction: A nationwide cohort study using Medicare data

“…In our study, >90 % of patients were taking clopidogrel, but current guidelines recommend prasugrel or ticagrelor over clopidogrel after acute coronary syndromes (ACSs) [ 1 , 73 , 74 ]; however, this recommendation is not without controversy, especially in older patients and patients with higher bleeding risks [ 75 ]. Prasugrel is often not recommended in patients >75 years old [ 1 , 74 , 75 ], and meta-analysis of RCTs in older adults found 1-year ticagrelor versus clopidogrel after ACS had no effect on composite cardiovascular death, AMI, and stroke (RR 1.04; 95 % CI: 0.69, 1.65) but was associated with an increased risk of major or minor bleeding (RR 1.40; 95 % CI: 1.11, 1.76) [ 76 ]. Among patients discharged after July 1, 2011 in our study—once all P2Y 12 inhibitors were available on the market—4.2 % took ticagrelor, 8.5 % took prasugrel, and 87.3 % took clopidogrel.…”

Evaluation of the long-term prognostic ability of triglyceride-glucose index for elderly acute coronary syndrome patients: a cohort study

“…Author details 1 Senior Department of Cardiology, The Sixth Medical Center, Chinese PLA General Hospital and Chinese PLA Medical School, Beijing 100853, China. 2 Department of Geriatrics, The Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China. 3 Department of Cardiology, Hainan Hospital, Chinese PLA General Hospital, Sanya 572000, Hainan, China.…”

“…Coronary heart disease (CHD) is the number one killer threatening human health, and the incidence increases significantly with age [1]. With the aggravation of population aging, the proportion of elderly patients hospitalized for acute coronary syndrome (ACS) is increasing, and studies showed that more than 30% of patients are over 75 years old [2,3]. The risk of bleeding and acute myocardial infarction post-percutaneous coronary intervention (re-MI) at 1-year follow-up is more than doubled in elderly patients [4].…”

The effect of ticagrelor on coronary microvascular function after PCI in patients with ACS compared to clopidogrel: A systematic review and meta-analysis

“…Dual antiplatelet therapy (DAPT) is the mainstay of pharmacotherapy for patients with ACS receiving PCI therapy [ 1 ]. Recent clinical studies have shown that ticagrelor has a better effect on the short-term prognosis of patients with ACS who undergo PCI than clopidogrel [ 6 ]. Pharmacodynamic studies have demonstrated that platelet inhibition by ticagrelor is greater and faster than that by clopidogrel [ 7 ].…”