Key result
Ticagrelor plus aspirin reduced the risk of new stroke compared to clopidogrel plus aspirin in non-smokers with minor stroke or TIA (5.3% vs 13.5%; HR 0.39; 95% CI 0.17-0.91; P=0.01).
Why the study?
It was unclear whether smoking status impacts platelet reactivity and clinical outcomes of ticagrelor versus clopidogrel in patients with acute minor stroke or TIA.
Does ticagrelor plus aspirin improve platelet reactivity and reduce stroke risk compared to clopidogrel plus aspirin in patients with minor stroke or TIA, and does smoking status modify this effect?
RCT (n=675)
randomized
Does ticagrelor plus aspirin improve platelet reactivity and reduce stroke risk compared to clopidogrel plus aspirin in patients with minor stroke or TIA, and does smoking status modify this effect?
Ticagrelor plus aspirin is superior to clopidogrel plus aspirin in inhibiting platelet reactivity and reducing new stroke risk in patients with minor stroke or TIA, with the clinical benefit driven primarily by non-smokers.
Ticagrelor may reduce new stroke risk more than clopidogrel in non-smokers with minor stroke/TIA; extends PRINCE subgroup evidence on smoking interaction.
BACKGROUND AND PURPOSE: It remains unclear whether smoking status has an impact on platelet reactivity and clinical outcomes of ticagrelor versus clopidogrel in patients with acute minor stroke or transient ischaemic attack (TIA). METHODS: A subgroup analysis of a randomized controlled trial was conducted. Patients with minor stroke or TIA were randomized for treatment with ticagrelor plus aspirin or clopidogrel plus aspirin. Platelet reactivity was assessed by VerifyNow P2Y12 assay at baseline, 7 + 2 days and 90 ± 7 days. High on-treatment platelet reactivity (HOPR) was defined as P2Y12 reaction units >208. Clinical outcomes included any stroke, composite clinical vascular events and bleeding events at 90 days. Patients who smoked one or more cigarettes per day for at least 1 year in their lives were defined as smokers. RESULTS: Of 675 patients enrolled in the trial, 370 patients (54.8%) were smokers. At 7 + 2 days, the proportion of HOPR in ticagrelor versus clopidogrel was significantly lower in smokers (5.2% vs. 21.8%) and non-smokers (2.3% vs. 34.4%). There were marginal significant interactions between treatment groups and smoking status for the proportion of HOPR (P = 0.058). At 90 ± 7 days, there were significant interactions between treatment groups and smoking status for the risk of new stroke (smokers: 7.0% vs. 4.9%; hazard ratio, 1.57; 95% confidence interval, 0.65-3.79; P = 0.39; non-smokers: 5.3% vs. 13.5%; hazard ratio, 0.39; 95% confidence interval, 0.17-0.91; P = 0.01; P for interaction = 0.02). CONCLUSIONS: Among patients with minor stroke or TIA, ticagrelor was superior to clopidogrel in inhibiting platelet reactivity and reducing the risk of new stroke, particularly for non-smokers.
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Yang et al. (2020) conducted an RCT in acute minor stroke or transient ischaemic attack (TIA) (n=675). Ticagrelor plus aspirin vs. Clopidogrel plus aspirin was evaluated on risk of new stroke at 90 days in non-smokers (HR 0.39, 95% CI 0.17-0.91, p=0.01). Ticagrelor plus aspirin reduced the risk of new stroke compared to clopidogrel plus aspirin in non-smokers with minor stroke or TIA (5.3% vs 13.5%; HR 0.39; 95% CI 0.17-0.91; P=0.01).
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