C-59 | Ticagrelor or Prasugrel Versus Clopidogrel for Acute Coronary Syndrome in Patients on Oral Anticoagulation for Atrial Fibrillation; A Single Center Experience

Potent P2Y12 inhibitors Ticagrelor or Prasugrel (T/P) have a stronger anti-platelet effect compared to clopidogrel (C). Data comparing T/P to C is lacking in patients with acute coronary syndrome (ACS) on oral anticoagulation (OAC) with a vitamin-K antagonist (VKA) or direct oral anticoagulants (DOACs) for Atrial Fibrillation (AF). With this review we sought to compare T/P versus (vs) C in patients with ACS on OAC for AF. A total of 8,119 patients who underwent Percutaneous Coronary Intervention (PCI) for ACS between January 2016 - August 2023 were retrospectively screened at our institution. Patients on T/P or C following PCI also on OAC for AF were then identified. 201 met the inclusion criteria. The primary endpoint was a composite of net adverse clinical events (NACE) including major adverse cardiac and cerebrovascular events (MACCE) and any bleeding. The secondary endpoints were MACCE; a composite of all-cause mortality, myocardial infarction (MI), stent thrombosis, stroke, and any bleeding; a composite of major, clinically relevant non major (CRNM) or minor bleeding classified by the International Society on Thrombosis and Haemostasis (ISTH), and anti-thrombotic therapy at discharge. 141 patients received T/P and 60 received C. The mean follow up was 21 (±17.9) months. Triple anti-thrombotic therapy was significantly more common in the T/P group vs C group (47.6% vs 8.9%, respectively; odds ratio [OR], 4.97; 95% confidence interval [CI], 2.58-9.59, p < 0.05). VKA use was significantly less in the T/P group compared to the C group (10.4% vs 8.9%; OR, 0.49; 95% CI, 0.24-0.99, p < 0.05). After multi-variate adjustment, in patients post PCI, T/P compared to C in the setting of OAC for AF, no significant difference was noted in NACE ( 32.3% vs 10.9%; adjusted odds ratio [aOR], 0.60; 95% CI, 0.27-1.30, p =0.20) or MACCE (21.8% vs. 9.4%; aOR, 1.6; 95% CI, 0.47-2.4, p =0.88) or any bleeding (17.4% vs 5.9%; aOR, 0.55; 95% CI, 0.22-1.403, p =0.21). Our retrospective study showed that in patients on OAC for AF who underwent PCI, T/P was comparable to C in terms of NACE, MACCE and bleeding outcomes. Future large prospective randomized controlled trials are warranted to compare T/P to C in this patient population.