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Efficacy and Safety of Clopidogrel, Prasugrel and Ticagrelor in ACS Patients Treated with PCI: A Propensity Score Analysis of the RENAMI and BleeMACS Registries

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Abstract

Introduction

Real-life data comparing clopidogrel, prasugrel, and ticagrelor for unselected patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) are lacking, as are data for the temporal distribution of ischemic and bleeding risks.

Methods

A total of 19,825 patients were enrolled from the RENAMI and BleeMACS registries. Both were multicenter, retrospective, observational registries including the data and outcomes of consecutive patients with ACS who underwent primary PCI and were discharged with dual antiplatelet therapy (DAPT). We evaluated the long-term outcome stratified by the different antiplatelet agents.

Results

A total of 14,105 patients (71.2%) were treated with clopidogrel, 2364 patients (11.9%) with prasugrel and 3356 patients (16.9%) with ticagrelor. After propensity score matching, at 1 year, prasugrel reduced the incidence of net adverse clinical events (NACE; a composite endpoint of all-cause death, myocardial infarction [MI] and Bleeding Academic Research Consortium [BARC] 3–5 bleeding) (4.2% vs.7.6%, p = 0.002) and of major adverse cardiovascular events (MACE; a composite endpoint of death and MI) compared with clopidogrel (2.6% vs. 5.2%, p = 0.007). Ticagrelor decreased rates of MACE compared with clopidogrel (2.7% vs. 6.2%, p < 0.001), but not of NACE (6.6% vs. 8.7%, p = 0.07). Ticagrelor presented similar performance in terms of MACE compared with prasugrel (2.8% vs. 2.4%, p = 0.56), with a trend towards a reduction in MI (0.2% vs. 0.4%, p = 0.56), but with higher risk of BARC 3–5 bleedings (3.8% vs. 1.7%, p = 0.04). In the daily risk analysis, clopidogrel presented a binomial distribution with a peak of ischemic risk at 3 months, which decreased towards bleedings; prasugrel had a constant equivalence between opposite risks; and ticagrelor constantly reduced recurrent MIs despite higher risk of BARC 3–5 events.

Conclusion

In real life, ticagrelor is more effective in reducing ischemic events during the first year after ACS, despite an increased risk of major bleedings, while prasugrel assures a better balance between ischemic and bleeding recurrent events.

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Authors and Affiliations

  1. Division of Cardiology, Department of Medical Sciences, University of Torino, Turin, Italy

    Mattia Peyracchia, Andrea Saglietto, Carloalberto Biolè, Michele Autelli, Alberto Grosso, Maurizio D’Amico, Walter Grossomarra, Tullio Usmiani, Mauro Rinaldi & Fabrizio D’Ascenzo

  2. Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain

    Sergio Raposeiras-Roubin, Emad Abu-Assi, Berenice Caneiro Queija, Rafael Cobas Paz, María Cespón Fernández, Isabel Muñoz Pousa & Andrés Iñiguez-Romo

  3. Cardiology Department, University Hospital of Wales, Cardiff, UK

    Tim Kinnaird

  4. Department of Cardiology, University Hospital de Bellvitge, Barcelona, Spain

    Albert Ariza-Solé, Alberto Garay & Angel Cequier

  5. Kerckhoff Heart and Thorax Center, Frankfurt, Germany

    Christoph Liebetrau

  6. Department of Cardiology, University Hospital Virgen Arrtixaca, Murcia, Spain

    Sergio Manzano-Fernández, Pedro Flores Blanco & Angel Lopez-Cuenca

  7. Division of Cardiology, Universitaspital, Zurich, Switzerland

    Sebastiano Gili & Giulia Magnani

  8. Cardiovascular Institute of Alberta, Calgary, Canada

    Stephen B. Wilton

  9. Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

    Jose Paulo Simao Henriques

  10. Hospital Sao Rafael, Salvador, Brazil

    Luis Correia

  11. Institute of Cardiovascular Diseases, Vojvodina, Serbia

    Lazar Velicki

  12. University Patras Hospital, Athens, Greece

    Ioanna Xanthopoulou & Dimitrios Alexopoulos

  13. Interventional Unit, San Luigi Gonzaga University Hospital, Orbassano and Infermi Hospital, Rivoli (Turin), Turin, Italy

    Giorgio Quadri

  14. San Carlos Hospital, Madrid, Spain

    Iván Nuñez-Gil

  15. Department of Cardiology, Faculty of Medicine, Assiut University, Asyut, Egypt

    Salma Taha

  16. Tokai University School of Medicine, Tokyo, Japan

    Toshiharu Fujii

  17. Catheterization Laboratory, Maggiore della Carità Hospital, Novara, Italy

    Andrea Rognoni

  18. Department of Cardiology, S.G. Bosco Hospital, Turin, Italy

    Giacomo Boccuzzi, Ugo Fabrizio & Andrea Montabone

  19. U.O. Cardiologia, Ospedale Valduce, Como, Italy

    Alessandro Durante

  20. University Graduate School of Medicine, Kyoto, Japan

    Tetsuma Kawaji

  21. University Clinical Hospital, Warsaw, Poland

    Zenon Huczek

  22. University Clinical Hospital, Santiago de Compostela, Spain

    José Ramón González-Juanatey

  23. Institute of Heart Lung and Blood vessel disease, Beijing, China

    Shao-Ping Nie

  24. University Graduate School of Medicine, Kanazaw, Japan

    Masa-aki Kawashiri

  25. PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy

    Diego Gallo & Umberto Morbiducci

  26. Servicio de Cardiologìa, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain

    Alberto Dominguez-Rodriguez

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  1. Mattia Peyracchia
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  2. Andrea Saglietto
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Correspondence to Mattia Peyracchia.

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Peyracchia, M., Saglietto, A., Biolè, C. et al. Efficacy and Safety of Clopidogrel, Prasugrel and Ticagrelor in ACS Patients Treated with PCI: A Propensity Score Analysis of the RENAMI and BleeMACS Registries. Am J Cardiovasc Drugs 20, 259–269 (2020). https://doi.org/10.1007/s40256-019-00373-1

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