Clopidogrel or Ticagrelor in Patients with Acute Coronary Syndrome Treated with New-Generation DES: CHANGE DAPT

Courtesy of Dr. Pablo Baglioni.

This is a prospective observational study with a 1-year follow-up analyzing 2062 patients with acute coronary syndrome (ACS) who have been treated with coronary angioplasty using new-generation drug-eluting stents (DES).

Patients were included between December 21, 2012 and August 25, 2015. On May, 2014, due to changes in international guidelines, clopidogrel was replaced by ticagrelor. In consequence, group 1 included patients from the clopidogrel period (CP) and group 2 included patients after this date (ticagrelor period [TP]).

Read also: “Complex PCI: DAPT defining factor?”

Patients who were pregnant and patients whose life expectancy was < 1 year, with planned elective surgery requiring the interruption of dual antiplatelet therapy (DAPT) within 6 months, were excluded from this study. Furthermore, patients treated with oral anticoagulation at baseline were not included either.

If patients were not on antiplatelet therapy at the time of the procedure, doses of aspirin (300 mg) and a loading dose of clopidogrel (600 mg) or ticagrelor (180 mg) were administered. Maintenance doses were 80-100 mg aspirin and 75 mg clopidogrel or 90 mg ticagrelor twice daily, depending on the group. Dual antiplatelet therapy was continued for 12 months, as in regular treatment for ACS.

Read also: “When and How to Switch Dual Antiplatelet Therapies”.

Of all 2062 patients enrolled, 1009 were treated with clopidogrel and 1053 were treated with ticagrelor. Patients in the ticagrelor group were older (62.9 ± 11.6 vs. 63.9 ± 12.1 years; p = 0.04) and experienced less peripheral vascular disease (8.8% vs. 5.5%; p = 0.03).

Transradial access was more common among patients who received ticagrelor (17.7% vs. 44.6%; p =< 0.001); the number of diseased vessels lacked statistical significance, and so did the stent type (everolimus, zotarolimus, or sirolimus).

One-year follow-up was successful in 99.3% of patients. Primary events occurred in 5.1% of all patients in the clopidogrel group vs. 7.8% of patients in the other group. This increased rate of primary events in the second group was largely caused by a difference in major bleeding, 1.2 vs. 2.7% (p = 0.02).

As regards other endpoints such as acute myocardial infarction, stroke, or all-cause death, there were no significant differences.

Editorial Comment

This study found that patients treated with ticagrelor had significantly higher rates of the primary endpoints. It also could not prove the non-inferiority of ticagrelor over clopidogrel. Upon multivariate analyses, authors found that the use of ticagrelor was an independent predictor of the primary endpoints and major bleeding, although proton pump inhibitors were more frequently prescribed to prevent gastrointestinal bleeding.

Read also: “Angioplasty Complexity May Define the Duration of Dual Antiplatelet Therapy”.

While the results of this study do not differ from others conducted before, they still highlight the importance of identifying the patient group who should receive each antiplatelet agent, assessing risks and benefits of each type, and becoming acquainted with the correct way to switch them in order to avoid complications.

Courtesy of Dr. Pablo Baglioni.

Original title: Clopidogrel or Ticagrelor in Acute Coronary Syndrome Patients Treated with Newer-Generation Drug-Eluting Stents: CHANGE DAPT.

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