Original Title: Ticagrelor for Prevention of Ischemic Events after Myocardial Infarction in Patients with Peripheral Artery Disease.

Reference: Marc P. Bonaca et al. J Am Coll Cardiol. 2016 Jun 14;67(23):2719-28.

Peripheral artery disease is associated with high rates of ischemic and bleeding events in patients with prior myocardial infarction.

This study evaluates the safety and efficacy of ticagrelor on major adverse cardiovascular and limb events in patients with peripheral artery disease and prior myocardial infarction.

The PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin—Thrombolysis in Myocardial Infarction 54) randomized 21,162 patients with prior MI (1 to 3 years before randomization) to ticagrelor 90 mg. every 12 hours, ticagrelor 60 mg. every 12 hours, or placebo (all in addition to low doses of aspirin).

1,143 (5% of total patients) presented peripheral artery disease. Researchers analyzed cardiovascular events (cardiovascular death, MI or stroke) and adverse limb events rates (acute ischemia or the need for ischemia driven peripheral revascularization).

Those in the placebo arm with peripheral artery disease (n=404) had higher rates of major cardiovascular events at 3 years than those without peripheral artery disease (n = 6,663; 19.3% vs. 8.4%; p < 0.001). This difference persisted after adjusting. What is more, those with peripheral artery disease presented higher rates of acute limb ischemia (1.0% vs. 0.1%) and more need for peripheral revascularization (9.15% vs. 0.46%).

The relatively reduced risk with ticagrelor was consistent regardless of peripheral artery disease. In fact, those with intermittent claudication showed better absolute risk reduction (number needed to treat: 25) given the higher absolute risk at baseline.

The absolute excess of TIMI major bleeding was 0.12% (number needed to harm: 834).

The 60 mg. arm saw more benefits as regards cardiovascular mortality and all- cause mortality.

Finally, ticagrelor (considering both doses) reduced limbs events risk (HR: 0.65; CI 95% 0.44 a 0.95; p = 0.026).

Conclusion

Patients with prior acute myocardial infarction and peripheral artery disease presented higher risk of ischemic events. In these patients, ticagrelor reduces major adverse cardiovascular events and major adverse limb events.

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