Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial

Abstract

Objective To evaluate efficacy and safety outcomes in patients in the PLATelet inhibition and patient Outcomes (PLATO) trial who at randomisation were planned for a non-invasive treatment strategy.Design Pre-specified analysis of pre-randomisation defined subgroup of prospective randomised clinical trial.Setting 862 centres in 43 countries.Participants 5216 (28%) of 18 624 patients admitted to hospital for acute coronary syndrome who were specified as planned for non-invasive management.Interventions Randomised treatment with ticagrelor (n=2601) versus clopidogrel (2615).Main outcome measurements Primary composite end point of cardiovascular death, myocardial infarction, and stroke; their individual components; and PLATO defined major bleeding during one year.Results 2183 (41.9%) patients had coronary angiography during their initial hospital admission, 1065 (20.4%) had percutaneous coronary intervention, and 208 (4.0%) had coronary artery bypass surgery. Cumulatively, 3143 (60.3%) patients had been managed non-invasively by the end of follow-up. The incidence of the primary end point was lower with ticagrelor than with clopidogrel (12.0% (n=295) v 14.3% (346); hazard ratio 0.85, 95% confidence interval 0.73 to 1.00; P=0.04). Overall mortality was also lower (6.1% (147) v 8.2% (195); 0.75, 0.61 to 0.93; P=0.01). The incidence of total major bleeding (11.9% (272) v 10.3% (238); 1.17, 0.98 to 1.39; P=0.08) and non-coronary artery bypass grafting related major bleeding (4.0% (90) v 3.1% (71); 1.30, 0.95 to 1.77; P=0.10) was numerically higher with ticagrelor than with clopidogrel.Conclusions In patients with acute coronary syndrome initially intended for non-invasive management, the benefits of ticagrelor over clopidogrel were consistent with those from the overall PLATO results, indicating the broad benefits of P2Y12 inhibition with ticagrelor regardless of intended management strategy.Trial registration Clinical trials NCT00391872.

Pretreatment with P2Y 12 Inhibitors in Non–ST-Segment–Elevation Acute Coronary Syndrome: An Outdated and Harmful Strategy

“…This short time delay may be perceived as a limitation for the applicability of ACCOAST in the real-life setting. However, as shown in Figure 6B, this time delay is similar to what was observed in contemporary ACS studies, 2,[43][44][45][46] which are used to recommend rapid invasive management in high-risk NSTEMI. In addition, no interaction was observed between time delay from randomization to angiography and outcome, outlining that the lack of benefit of pretreatment is consistent regardless of time delay.…”

Antiplatelet therapy in acute coronary syndromes

“…Importantly, the advantages of ticagrelor were seen regardless of whether invasive or non-invasive management was planned [69,70]. In the patients undergoing planned invasive treatment (PCI or CABG), ticagrelor led to a greater reduction in ischaemic events than clopidogrel (9.0 vs. 10.7%; HR 0.84, 95% CI 0.75 to 0.94; p = 0.0025) without any increase in major bleeding [69].…”

COMPARISON OF THE ORIGINAL (PLAVIx) AND GENERIC (CLAPITAx) CLOPIDOGREL ON PLATELET AGGREGATION: ObSERVATIONAL STUDY

“…Ключевой особенностью данного препарата являются быстрое начало дей-ствия, короткий период полужизни и обратимый характер связывания с соответствующими рецепто-рами, что удобно в неотложных ситуациях, а также в случаях вынужденной отмены препарата незадолго до внепланового аорто-коронарного шунтирования и реваскуляризации [7][8][9][10][11] (кроме раннего чрескож-ного коронарного вмешательства).…”