Key result
Ticagrelor-based DAPT is linked to ~2-fold higher 6-month bleeding versus clopidogrel without reducing MACE in STEMI.
Why the study?
Potent P2Y12 inhibition is guideline-recommended after STEMI, but bleeding complications are common and linked to worse outcomes, prompting evaluation of real-world bleeding risks.
Does a ticagrelor-based DAPT strategy increase the incidence of bleeding events compared to a clopidogrel-based DAPT strategy in a real-world population of STEMI patients over 6 months?
Cohort (n=660)
Yes
Does a ticagrelor-based DAPT strategy increase the incidence of bleeding events compared to a clopidogrel-based DAPT strategy in a real-world population of STEMI patients over 6 months?
In an unselected, older real-world STEMI cohort, switching to a routine ticagrelor-based DAPT strategy more than doubled post-discharge bleeding complications (including major bleeds and bleeding hospitalizations) over 6 months without a significant reduction in death, MI, or stroke.
Answers are grounded in this paper and cite their sources.
May favor clopidogrel-based DAPT to limit bleeding in unselected STEMI; leaves open randomized confirmation of net benefit.
INTRODUCTION: Dual antiplatelet therapy (DAPT), including potent P2Y12 inhibition after ST-elevation myocardial infarction (STEMI) is recommended in clinical guidelines. However, bleeding complications are common, and associated with worse outcomes. The aim of this study was to assess incidence of bleeding events with a clopidogrel-based compared to a ticagrelor-based DAPT strategy, in a real world population. Secondary aims were to assess ischemic complications and mortality. METHODS AND RESULTS: We identified 330 consecutive STEMI patients with a clopidogrel-based and 330 with a ticagrelor-based DAPT strategy. Patientś medical records were searched for bleeding and ischemic complications, over 6 months follow-up.The two groups were well balanced in baseline characteristics, age (69 years inboth groups), sex (31% vs 32% females), history of diabetes (19% vs 21%), hypertension (43% in both) and MI (17% vs 15%). There was no difference in CRUSADE bleeding score (28 vs 29). After discharge, there were more than twice as many bleeding events with a ticagrelor-based compared with a clopidogrel-based strategy (13.3% vs. 6.5%, p = 0.005). Bleeding events included significantly more severe bleeding complications (TIMI major/minor [5.8 vs 1.0, p = 0.001]) during the ticagrelor-based period. There was no significant difference in the composite of death, MI or stroke (7.8% vs 7.1%, p = 0.76). CONCLUSIONS: In this observational study, a ticagrelor-based DAPT strategy was associated with significantly more bleeding complications, without any significant change in death, MI or stroke. Larger studies are needed to determine whether bleeding complications off-sets benefits with a more potent DAPT strategy in older and more comorbid real-life patients.
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Alfredsson et al. (2020) conducted a cohort in ST-elevation myocardial infarction (STEMI) (n=660). Ticagrelor-based dual antiplatelet therapy (DAPT) strategy vs. Clopidogrel-based dual antiplatelet therapy (DAPT) strategy was evaluated on Any non-CABG bleeding complication from hospital discharge to 6 months follow-up (p=0.005). Ticagrelor-based DAPT doubled post-discharge 6-month bleeding compared to clopidogrel-based DAPT in real-world STEMI patients (13.3% vs 6.5%, p=0.005) without reducing MACE (7.1% vs 7.8%, p=0.76).
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