Ticagrelor Versus Clopidogrel in Acute Coronary Syndromes in Relation to Renal Function
Key result
Ticagrelor cuts major events ~23% vs clopidogrel in ACS patients with CKD.
- HR 0.77
- 95% CI 0.65 to 0.90
- n=15,202
Why the study?
Reduced renal function in ACS is associated with poorer prognosis and higher bleeding risk, potentially altering the risk-benefit ratio of antiplatelet therapies.
Does ticagrelor reduce the composite of cardiovascular death, myocardial infarction, and stroke compared to clopidogrel in patients with acute coronary syndromes and chronic kidney disease?
Population
15 202 ACS patients with baseline serum creatinine in the PLATO trial
Comparison
Ticagrelor vs clopidogrel
Design
Substudy of a randomized trial
Follow-up
12 months
Authors
Discussion
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Member takes
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“A large proportion of patients with MI also have kidney disease and these results show that ticagrelor, as compared to clopidogrel, was associated with significantly lower risk of ischaemic outcomes in patients with moderate renal dysfunction.”
“Despite the increased risk for adverse outcomes, CKD patients presenting with ACS are less likely to receive evidence-based therapies, including medications. In addition, patients with CKD have been under represented in randomized controlled trials of ACS pharmacotherapy.”
“Certainly, we recognize and understand that bleeding happens in kidney disease patients, but so does MI. The events happen at similar rates but it looks like our decision-making is driven so much by the concern for bleeding, which is justifiable, that we may be depriving certain patients who could benefit from prasugrel.”
Implication
Supports ticagrelor over clopidogrel in ACS with CKD; extends PLATO benefits to this high-risk subgroup.
Key Points
- This research aims to evaluate the efficacy and safety of ticagrelor compared to clopidogrel in patients with acute coronary syndrome and reduced renal function.
- Analyzed data from the PLATO trial including 15,202 acute coronary syndrome patients.
- Calculated creatinine clearance using the Cockcroft Gault equation.
- Compared outcomes between 3,237 patients with chronic kidney disease and 11,965 with normal renal function.
- In chronic kidney disease patients, ticagrelor significantly reduced the primary composite endpoint to 17.3% from 22.0% (HR 0.77, 95% CI 0.65 to 0.90).
- Total mortality decreased from 14.0% to 10.0% with ticagrelor (HR 0.72, 95% CI 0.58 to 0.89).
- No significant difference in major bleeding rates was observed between the two groups, with rates of 15.1% for ticagrelor and 14.3% for clopidogrel (HR 1.07, 95% CI 0.88 to 1.30).
Study Design
Type
RCT (n=15,202)
Multicenter
Yes
Structured PICO
Does ticagrelor reduce the composite of cardiovascular death, myocardial infarction, and stroke compared to clopidogrel in patients with acute coronary syndromes and chronic kidney disease?
P
Population
15,202 patients with acute coronary syndromes, including 3,237 with chronic kidney disease, followed for 12 months.
I
Intervention
Ticagrelor
C
Comparator
Clopidogrel
O
Outcome
Composite of cardiovascular death, myocardial infarction, and stroke at 12 monthscomposite
Main Result
Hazard Ratio: 0.77 (95% CI 0.65–0.9)
Absolute Event Rate: 17.3% vs 22%
Ticagrelor provides a significant reduction in ischemic endpoints and mortality compared to clopidogrel in ACS patients with chronic kidney disease, without a significant increase in major bleeding.
Cite This Study
James et al. (2010) conducted an RCT in Acute coronary syndromes (n=15,202). Ticagrelor vs. Clopidogrel was evaluated on Composite of cardiovascular death, myocardial infarction, and stroke in patients with chronic kidney disease (HR 0.77, 95% CI 0.65 to 0.90). In ACS patients with chronic kidney disease, ticagrelor reduced cardiovascular death, MI, and stroke compared with clopidogrel (17.3% vs 22.0%; HR 0.77; 95% CI 0.65-0.90).