Should elderly patients stick to clopidogrel? The first large study on prasugrel showed an unacceptable increase of bleeding in elderly patients, suggesting the use of 5 mg (although the sample size was small, which hindered the determination of dose efficacy).
Later, ticagrelor showed better efficacy than clopidogrel without apparent safety concerns. However, specific evidence on elderly populations with infarction has always been limited.
This paper published in Circulation gathered information from 14,005 elderly patients—80 years old and up—included in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry discharged with an indication of aspirin plus clopidogrel (60.2%) or ticagrelor (39.8%) after acute myocardial infarction.
The primary efficacy endpoint was a composite of death, infarction, or stroke, and the primary safety endpoint was bleeding after a 1-year follow-up.
The incidence of the composite primary endpoint of ischemic events was basically identical for ticagrelor and clopidogrel (hazard ratio: 0.97; 95% confidence interval: 0.88–1.06).
Read also: Angioplasty in Aspirin-Free Stable Patients with Prasugrel: Innovation Continues.
When analyzing each individual endpoint, ticagrelor was associated with a 17% higher risk of death and a 48% higher risk of bleeding. At the same time, it presented a 20% lower risk of infarction and an almost 30% lower risk of stroke. The sum of these different risks results in a draw as regards the composite endpoint between ticagrelor and clopidogrel.
A sensitivity analysis in a population <80 years old had different results. For “younger” patients, ticagrelor diminished mortality, infarction, and stroke, without such a pronounced raise in bleeding.
Conclusion
Elderly patients with acute myocardial infarction discharged with ticagrelor show a higher risk of death and bleeding compared to clopidogrel. A randomized study in this population should be conducted.
Original Title: Comparison Between Ticagrelor and Clopidogrel in Elderly Patients with an Acute Coronary Syndrome: Insights from the SWEDEHEART Registry.
Reference: Karolina Szummer et al. Circulation. 2020 Nov 3;142(18):1700-1708. doi: 10.1161/CIRCULATIONAHA.120.050645.
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