ESC Congress 2017 In Review – Focus on CAD&ACS - 20

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The study comprised 6,183 patients (ticagrelor, n = 4,269;
prasugrel, n = 1,914. In clinical practice ticagrelor was
used more often than prasugrel. Patients treated with
ticagrelor were older (68.7 vs 61.1 years; P < .001) than
those who received prasugrel, and were more likely to
be women (28.9% vs 21.7%; P < .001). They also had
more comorbidities, including peripheral artery disease
(9.5% vs 6.0%; P < .001) and renal insufficiency (19.2%
vs 11.2%; P < .001), and were also more likely to have
undergone prior coronary artery bypass grafting (10.0%
vs 5.8%; P < .001). Prasugrel patients in the Core
Population (ticagrelor, n = 2,716; prasugrel, n = 1,656)
were also older and sicker compared with those who
received ticagrelor.
The rates for nonfatal stroke and bleeding complications (defined as severe bleeding requiring transfusion) were similar between the 2 treatments, despite
numerically more bleeds in the prasugrel group overall
and in the Core Population. In-hospital mortality and
the short-term safety profile were also comparable. The
highest rates of in-hospital mortality and major adverse
cardiovascular and cerebrovascular events (MACCE)
were in ticagrelor patients both overall and in the Core
Population (1.6% and 1.9% vs 1.0% and 1.2%; in-hospital
mortality and MACCE, ticagrelor vs prasugrel, respectively). In-hospital outcomes for the Core Population are
shown in Table 1. This study is limited in that no longterm follow-up is available.
Table 1. Propensity Score Analysis: Core Population In-hospital
Outcome
Outcome

OR (95% CI)

P value

Nonfatal stroke

1.93 (0.17 - 21.34)

.6

Bleeding

0.57 (0.22 - 1.42)

.2

In-hospital mortality

1.06 (0.49 - 2.29)

.9

MACCE

1.17 (0.58 - 2.39)

.7

MACCE, major adverse cardiovascular and cerebrovascular event.

Patients With ACS and CKD
Among patients in the PLATO trial who had both ACS
and CKD, ticagrelor was a more effective than clopidogrel in reducing ischaemic end points (HR, 0.77; 95%
CI, 0.65 to 0.90) and mortality (HR, 0.72; 95% CI, 0.58 to
0.89) without a significant increase in major bleeding
regardless of renal function. The benefits were larger
with worse poor renal function and without the need for
dose reduction to prevent major bleeding [James S et
al. Circulation. 2010].
However, according to Robert Edfors, MD, Karolinska
Institute, Stockholm, Sweden, clinical data are lacking on the comparative efficacy of these drugs in MI

20

October 2017

patients with renal dysfunction. He reported findings
from a recent study that used data from the Swedish
MI registry (SWEDEHEART). The study included 45,206 MI
patients 36,392 of whom underwent PCI. Patients were
stratified by creatinine based estimated glomerular filtration	rate	(eGFR)	>	60	(n	=	33,668),	30-60	(n	=	9,803),	and	
< 30 mL/min/m2 (n = 1,735) based on using the Chronic
Kidney Disease Epidemiology Collaboration [Levey AS et
al. Ann Intern Med. 2009].
At 1 year, patients on ticagrelor had a lower risk for
the combined primary endpoint of death, MI, or stroke
and for the secondary endpoint of death in patients
with	eGFR	30-60	and	eGFR	>	60	compared	with	those	
who received clopidogrel. The benefit of ticagrelor in
patients with eGFR < 30 mL/min/m2 was unclear, concluded Dr Edfors, and additional studies in this patient
subgroup are needed.
Future Perspectives
Based on current and emerging evidence, Robert F. Storey,
MD, University of Sheffield, United Kingdom, believes
that DAPT will remain the mainstay of antithrombotic
therapy following PCI and ACS, because of its effectiveness in preventing broad ischaemic events and acute
stent thrombosis, despite an increased risk of nonfatal
major bleeding. He highlighted some recommendations
from the recently published expert consensus paper of
the European Society of Cardiology Working Group on
Thrombosis [Halvorsen S et al. Eur Heart J. 2017], which
recommends that clinicians resume oral antithrombotic
therapy after a bleeding event in all cases with a clear
indication for therapy, provided that the bleeding is not
life-threatening. The guidelines also indicate that prolonged discontinuation of antithrombotic therapy following bleeding events, should be avoided, whenever
feasible. Dr Storey also highlighted data from PLATO
and PEGASUS-TIMI 54 demonstrating that GDF-15 concentration differentiated patients with low and high
bleeding risk.
Discussing new clinical trials in P2Y12 inhibitors, Dr
Storey noted the GLOBAL LEADERS trial [NCT01813435]
that is currently ongoing in all-comer patients undergoing PCI with bivalirudin and BioMatrix drug-eluting
stents. This trial will evaluate effectiveness of ticagrelor alone for 23 months after 1 month of DAPT versus
12-month standard DAPT, for long-term prevention of
adverse cardiac events. The TWILIGHT study [Baber U et
al. Am Heart J. 2016] is also enrolling, he added, and will
compare use of ticagrelor alone adverse standard therapy with ticagrelor and aspirin in high-risk PCI patients.
Considering all available and emerging data, future
studies should aim to identify optimal individualised
antithrombotic regimens, Dr Storey concluded.

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Table of Contents for the Digital Edition of ESC Congress 2017 In Review – Focus on CAD&ACS
