Key result
Ticagrelor significantly reduced the risk of major adverse cardiac and cerebrovascular events compared to clopidogrel (HR 0.540) in patients with acute coronary syndrome, though this benefit was primarily observed in the angiography-guided subgroup rather than the IVUS-guided subgroup.
Why the study?
The effect of different dual antiplatelet therapies on thrombotic events against a background of intravascular ultrasound (IVUS) guidance was unclear.
Does ticagrelor reduce major adverse cardiac cerebrovascular events compared to clopidogrel in patients with acute coronary syndrome treated with drug-eluting stents guided by intravascular ultrasound or angiography?
Cohort (n=5,666)
No
Does ticagrelor reduce major adverse cardiac cerebrovascular events compared to clopidogrel in patients with acute coronary syndrome treated with drug-eluting stents guided by intravascular ultrasound or angiography?
Hazard Ratio: 0.54 (95% CI 0.294–0.991)
Absolute Event Rate: 2.9% vs 5.7%
p-value: p=0.047
Ticagrelor reduces ischemic events compared to clopidogrel in ACS patients undergoing angiography-guided PCI, but this ischemic benefit is attenuated and bleeding risk is increased when PCI is guided by IVUS.
Ticagrelor ischemic benefit may be attenuated by IVUS guidance; hypothesis-generating for whether precise stenting reduces need for potent DAPT in ACS.
BACKGROUND: The effect of different dual antiplatelet therapies on thrombotic events on the background of intravascular ultrasound (IVUS) guidance is unclear. We investigated whether ticagrelor can provide any additional benefit to clopidogrel in reducing thrombotic events in acute coronary syndrome (ACS) treated with drug- eluting stent (DES), when guided by IVUS or not. METHODS: A total of 5,666 ACS patients who underwent DES implantation and who were discharged on dual antiplatelet therapy were enrolled and grouped according to the use of IVUS or not. Each group was subdivided into two subgroups according to the type of P2Y12 inhibitor used after discharge. Propensity score matching (PSM) was used between the IVUS and no-IVUS groups. Covariate adjustment of Cox proportional hazards model was used between the ticagrelor and clopidogrel groups. Thrombotic event at 12 months was compared in groups separately. RESULTS: After PSM, 12-month follow-up data were available for 1,174 patients. Major adverse cardiac events (MACE) were less frequent in the IVUS-guided group (2.2% vs. 4.3%, P = 0.081) with a trend toward statistical significance. Comparison of antiplatelet regimens revealed significantly fewer major adverse cardiac and cerebrovascular events (MACCE) with ticagrelor in the entire PSM cohort and angiography-guided subgroup (2.9% vs. 5.7%, P = 0.035; 3.1% vs. 6.4%, P = 0.020, respectively). Among patients in the IVUS-guided group the outcome was comparable (2.5% vs. 4.4%, P = 0.312). Ticagrelor was associated with increasing bleeding incidence in the entire PSM cohort (1.3% vs. 3.3%, P = 0.030), mainly due to Bleeding Academic Research Consortium type 2 bleeding (0.7% vs. 2.6%, P = 0.010). The results were consistent after covariate adjustment of Cox proportional hazards model. CONCLUSION: The comparison of ischemic benefit between ticagrelor and clopidogrel was similar in patients receiving IVUS guidance during stent implantation, probably due to the precise implantation of IVUS. Multicenter, randomized studies should be performed to validate this conclusion.
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Zhao et al. (2024) conducted a cohort in Acute coronary syndrome (ACS) (n=5,666). Ticagrelor vs. Clopidogrel (75 mg once daily) was evaluated on Major adverse cardiac and cerebrovascular events (MACCE), including cardiac death, myocardial infarction, and ischemic stroke (HR 0.540, 95% CI 0.294-0.991, p=0.047). Ticagrelor significantly reduced the risk of major adverse cardiac and cerebrovascular events compared to clopidogrel (HR 0.540) in patients with acute coronary syndrome, though this benefit was primarily observed in the angiography-guided subgroup rather than the IVUS-guided subgroup.
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