Key result
Clopidogrel lowers bleeding ~38% and reduces thrombotic events vs ticagrelor in older NSTE-ACS patients on OAC.
Why the study?
Randomised data were lacking on which antiplatelet agent to use in elderly patients with non-ST-elevation acute coronary syndrome and an indication for oral anticoagulation.
Does clopidogrel improve net clinical benefit compared to ticagrelor in patients ≥70 years with NSTE-ACS using oral anticoagulation?
RCT (n=184)
Does clopidogrel improve net clinical benefit compared to ticagrelor in patients ≥70 years with NSTE-ACS using oral anticoagulation?
Absolute Event Rate: 20.9% vs 33.5%
p-value: p=0.051
In older patients with NSTE-ACS on oral anticoagulation, clopidogrel provides a better net clinical benefit than ticagrelor by reducing thrombotic events and trending toward less bleeding.
Supports preferring clopidogrel over ticagrelor for net benefit in elderly anticoagulated NSTE-ACS; extends randomized evidence on P2Y12 selection in this high-risk group.
There are no randomised data on which antiplatelet agent to use in elderly patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and an indication for oral anticoagulation (OAC). The randomised POPular Age trial, in patients of 70 years or older with NSTE-ACS, showed a reduction in bleeding without increasing thrombotic events in patients using clopidogrel as compared to ticagrelor. In this sub-analysis of the POPular AGE trial, we compare clopidogrel with ticagrelor in patients with a need for oral anticoagulation. The follow-up duration was one year. The primary bleeding outcome was Platelet Inhibition and Patient Outcomes (PLATO) major and minor bleeding. The primary thrombotic outcome consisted of cardiovascular death, myocardial infarction and stroke. The primary net clinical benefit outcome was a composite of all-cause death, myocardial infarction, stroke, and PLATO major and minor bleeding. A total of 184/1011 (18.2%) patients on OAC were included in this subanalysis; 83 were randomized to clopidogrel and 101 to ticagrelor. The primary bleeding outcome was lower in the clopidogrel group (17/83, 20.9%) compared to the ticagrelor group (33/101, 33.5%; p = 0.051), as was the thrombotic outcome (7/83, 8.4% vs. 19/101, 19.2%; p = 0.035) and the primary net clinical benefit outcome (23/83, 27.7% vs. 49/101, 48.5%; p = 0.003). In this subgroup of patients using OAC, clopidogrel reduced PLATO major and minor bleeding compared to ticagrelor without increasing thrombotic risk. This analysis therefore suggests that, in line with the POPular Age trial, clopidogrel is a better option than ticagrelor in NSTE-ACS patients ≥70 years using OAC.
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Gimbel et al. (2020) conducted an RCT in Non-ST-elevation acute coronary syndrome (NSTE-ACS) with an indication for oral anticoagulation (n=184). Clopidogrel vs. Ticagrelor was evaluated on Platelet Inhibition and Patient Outcomes (PLATO) major and minor bleeding (p=0.051). In NSTE-ACS patients ≥70 years on oral anticoagulation, clopidogrel yielded lower PLATO major/minor bleeding (20.9% vs 33.5%, p=0.051) and thrombotic events (8.4% vs 19.2%, p=0.035) than ticagrelor.
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