ESC 2020 | Ticagrelor Might Increase Bleeding and Mortality in the Elderly

Ticagrelor compared against clopidogrel produces more bleeding and also more deaths in patients over 80 recently undergoing acute myocardial infarction.

Contrary to what has been observed in the general population, these data from the SWEDEHEART registry of post MI patients over 80, show higher bleeding and mortality rates with ticagrelor compared against clopidogrel.

These findings presented at ESC 2020 simultaneously published in Circulation are on the same line as the POPular AGE findings, where clopidogrel was shown superior to more potent antiaggregation drugs in patients over 70 undergoing non-ST elevation MI.

The SWEDEHEART registry included 14005 post-MI patients (31.6% with ST elevation) of 80 or more years of age. Most patients (60.2%) were discharged with clopidogrel, but since its introduction in 2012, ticagrelor rose steadily, reaching up to 72.5% in 2017.  

Read also: ESC 2020 | Rivaroxaban Might Reduce Cardiac Cerebral and Peripheral Events.

At one-year followup, ticagrelor patients presented fewer ischemic events (MI or stroke) but with increased mortality and hospitalization for bleeding events. 

This risk exceeded the benefit in ischemic events tilting the net clinical benefit in favor of clopidogrel for patients over 80.

Fort the population younger than 80, the balance between ischemia and bleeding remained stable, with no net clinical benefit in favor of neither drug (HR 0.95; CI 95% 0.89-1.01). 

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These finding are in contrast with the PLATO findings, which showed no interaction between age and treatment. We normally see these contradictions, since study populations are more thoroughly selected and therefore differ from “real life” populations. 

Optimal selection of a P2Y12 inhibitor (ticagrelor, low doses of prasugrel or clopidogrel) in elderly patients undergoing MI can be challenging and there are multiple factors we should take into account. 

Original Title: Comparison between ticagrelor and clopidogrel in elderly patients with an acute coronary syndrome: insights from the SWEDEHEART registry.

Reference: Szummer K et al. Circulation. 2020; Epub ahead of print y presentado en el congreso de la ESC 2020.

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