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CARDIOVASCULAR DISEASE
Ticagrelor may not confer post-MI benefits to elderly patients
Medical writer: [show_post_categories show=”author”] | Last updated: 8th October 2020 | In: [show_post_categories show=”category”]
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Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the standard treatment for acute coronary syndrome (ACS).1Wang D et al. BMC Cardiovasc Disord. 2018;18. Clopidogrel and ticagrelor are both P2Y12 receptor antagonists.2Shand JA et al. Biomark Med. 2011;5(1):53-62. Clopidogrel is an irreversible antagonist with a variable degree of platelet inhibition within the population, whereas ticagrelor is an orally active reversibly binding inhibitor with rapid onset of induced platelet aggregation.2Shand JA et al. Biomark Med. 2011;5(1):53-62. Ticagrelor was studied in a large, multicentre, randomised, double-blind PLATO trial, and showed a 16% relative risk reduction in composite cardiovascular death, myocardial infarction (MI), or stroke compared to clopidogrel.2Shand JA et al. Biomark Med. 2011;5(1):53-62.
However, recent analysis of the SWEDEHEART Registry, has indicated that ticagrelor use among elderly MI patients was associated with a higher risk of bleeding and death than with clopidogrel.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645Â The results were recently published in Circulation.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645
SWEDEHEART is a nationwide registry in Sweden that includes all consecutive patients admitted to a coronary care unit with symptoms that suggest ACS.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 Variables including baseline patient characteristics, medication on admission, in-hospital therapies, complications, and discharge medicines are collected.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 Inverse probability treatment weighting (IPTW) was used in analysis to reduce selection bias as treatments were not randomly assigned.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 The registry was used to compare clinical outcomes with ticagrelor versus clopidogrel among MI patients aged ≥80.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645
Of the 14,005 patients aged ≥80 who survived until discharge after an MI, 31.6% had a ST-segment elevation MI (STEMI) and 68.4% had a non-ST segment elevation MI (NSTEMI).3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 The majority (60.2%) were prescribed clopidogrel, and 39.8% were prescribed ticagrelor.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 Patients who received ticagrelor were younger and had fewer comorbidities at presentation.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 After Inverse Probability of Treatment Weighting (IPTW) adjustment, baseline characteristics were balanced.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645
The unadjusted analysis showed that patients treated with ticagrelor had significantly fewer combined ischaemic events or combined ischaemic/bleeding events.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 However, after IPTW Cox regression there was no significant reduction in combined ischaemic or combined ischaemic/bleeding endpoints with ticagrelor compared with clopidogrel treatment.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 Ticagrelor-treated patients had a 20% and 28% lower risk of new MI or stroke, respectively, compared with clopidogrel patients within one year.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 However, patients receiving ticagrelor had a 17% higher risk of dying and a 48% higher risk of re-admission due to a bleeding event than those treated with clopidogrel.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 In patients younger than 80 years, there was an 18% lower risk of MI, 18% lower risk of stroke, and a 15% lower risk of death, but 32% higher risk of bleeding events.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645
The results of this analysis indicate that current guideline recommendations should be applied with caution to the elderly population.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 There has been significant uptake in ticagrelor use over the study period, and nearly three quarters of all elderly patients at the end of 2017 were prescribed ticagrelor at discharger after a MI.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645 Thus, there is a need for a randomised controlled study to examine the effects of antiplatelet medications in the elderly population.3Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645
Reference
- Wang D et al. BMC Cardiovasc Disord. 2018;18.
- Shand JA et al. Biomark Med. 2011;5(1):53-62.
- Szummer Karolina et al. Circulation. doi: 10.1161/CIRCULATIONAHA.120.050645
Disclaimer
This article is not medical advice. Patients should seek personal assessment by a licenced specialist. Physicians are recommended to read the full publication(s) as cited in the article before making medical decisions. This article does not supersede nor replace the published article(s).
© Copyright 2020 MediPaper Medical Communications Ltd. – Ticagrelor may not confer post-MI benefits to elderly patients
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© Copyright 2020 MediPaper Medical Communications Ltd. – Ticagrelor may not confer post-MI benefits to elderly patients
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