James SK, Storey RF, Khurmi N, et al. Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes and a History of Stroke or Transient Ischemic Attack. Circulation 2012.

A sub-analysis of the PLATO study demonstrated similar superiority and the safety of ticagrelor in all patients, regardless of any previous history of stroke.

Ticagrelor versus clopidogrel: Equal efficacy and safety in patients with acute coronary syndrome and stroke history: At present, caution is recommended. 

Acute coronary syndrome (ACS) patients treated with angioplasty and stenting (ATC) who received the classical scheme of dual antiplatelet therapy (aspirin + clopidogrel) revealed ischemic type events over the short and long term, potentially attributable to inadequate platelet antiaggregation1. While the alternative use of prasugrel, a new irreversible antagonist of P2Y12 receptor, has demonstrated superior results to clopidogrel in ACS patients, its use is not recommended for patients at high risk of bleeding (weight

Commentary: On one hand, overall rate of intracranial bleeding in PLATO study was only 0.8%, much lower than in the TRITON study (prasugrel, 1.4%). On the other hand, the number of patients with a history of stroke / TIA included in this sub-analysis is relatively low. While these results generate hypothesis, they are not conclusive and by no means claim that it is safe to use ticagrelor in patients at high risk of bleeding, especially the intracranial type. For the moment these findings should be viewed with caution.

1.Wenger NK. 2011 ACCF/AHA focused update of the guidelines for the management of patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction (updating the 2007 Guideline): highlights for the clinician. Clin Cardiol 2012;35:3-8.

2.Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007;357:2001-15.

3.Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045-57.

4.James SK, Storey RF, Khurmi N, et al. Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes and a History of Stroke or Transient Ischemic Attack. Circulation 2012.

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