March 27, 2018
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Ticagrelor confers better ischemic outcomes after MI vs. clopidogrel regardless of renal function

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Patients treated with ticagrelor after MI had lower risk for death, MI or stroke than those treated with clopidogrel, regardless of estimated glomerular filtration rate, according to new data from the SWEDEHEART registry.

The researchers analyzed 45,206 patients, 36,392 of whom underwent PCI, who had MI between 2010 and 2013 and were discharged alive on dual antiplatelet therapy with aspirin plus clopidogrel or ticagrelor (Brilinta, AstraZeneca).

Patients were stratified by antiplatelet regimen and renal function. There were 24,130 patients with an estimated glomerular filtration rate (eGFR) greater than 60 mL/min/1.73 m2 using clopidogrel (median age, 67 years; 69% men), 9,538 patients with eGFR greater than 60 mL/min/1.73 m2 using ticagrelor (median age, 65 years; 74% men), 7,817 patients with eGFR 30 mL/min/1.73 m2 to 60 mL/min/1.73 m2 using clopidogrel (median age, 81 years; 55% men), 1,986 patients with eGFR 30 mL/min/1.73 m2 to 60 mL/min/1.73 m2 using ticagrelor (median age, 77 years; 59% men), 1,525 patients with eGFR less than 30 mL/min/1.73 m2 using clopidogrel (median age, 80 years; 56% men) and 210 patients with eGFR less than 30 mL/min/1.73 m2 using ticagrelor (median age, 78 years; 56% men).

The primary outcome was death, MI or stroke at 1 year. The secondary outcome was rehospitalization for bleeding at 1 year.

Ischemic outcomes

Among patients with eGFR greater than 60 mL/min/1.73 m2, the primary outcome occurred in 7% of those assigned ticagrelor vs. 11% of those assigned clopidogrel, whereas in patients with eGFR 30 mL/min/1.73 m2 to 60 mL/min/1.73 m2, the primary outcome occurred in 18% of those assigned ticagrelor and 33% of those assigned clopidogrel, and among patients with eGFR less than 30 mL/min/1.73 m2, the primary outcome occurred in 48% of those assigned ticagrelor and 64% of those assigned clopidogrel, Robert Edfors, MD, from the department of cardiology, Karolinska University Hospital, Stockholm, and colleagues wrote.

After adjustment, ticagrelor was associated with lower risk for the primary outcome vs. clopidogrel among patients with eGFR greater than 60 mL/min/1.73 m2 (HR = 0.87; 95% CI, 0.76-0.99), in those with eGFR 30 mL/min/1.73 m2 to 60 mL/min/1.73 m2 (HR = 0.82; 95% CI, 0.7-0.97) and among patients with eGFR less than 30 mL/min/1.73 m2 (HR = 0.95; 95% CI, 0.69-1.29; P for interaction by renal function = .55).

Bleeding outcomes

The researchers also found a numerically higher risk for the bleeding-related secondary outcome at 1 year associated with ticagrelor vs. clopidogrel across all renal function categories (HR for patients with eGFR > 60 mL/min/1.73 m2 = 1.1; 95% CI, 0.9-1.35; HR for patients with eGFR 30-60 mL/min/1.73 m2 = 1.13; 95% CI, 0.84-1.51; HR for patients with eGFR < 30 mL/min/1.73 m2 = 1.79; 95% CI, 1-3.21; P for interaction by renal function = .3).

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“Ticagrelor was associated with a lower risk of death or rehospitalization for MI or stroke than clopidogrel in patients with and without [chronic kidney disease], which supports previously shown benefits in PLATO,” Edfors and colleagues wrote. “Of caution, bleeding events were more abundant in patients with eGFR < 30, and there was a borderline interaction between ticagrelor and renal function regarding death, which may indicate that the balance between ischemia and risk of bleeding may differ in patients with advanced renal failure, warranting further studies in this specific subgroup.” – by Erik Swain

Disclosures: Edfors reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.