In addition to aspirin, Ticagrelor offers better prognosis in patients that already had a stroke and have a high-risk cardiovascular profile. These benefits should be correctly balanced seeing as they are not free of risk.
Antiplatelet therapy makes part of the standard treatment of cardiac or cerebrovascular patients. Ticagrelor has shown superior to clopidogrel in the Pivot study, especially thanks to its better safety in terms of bleeding in patients undergoing ACS.
Thinking all vascular territories present the same physiopathology and that the intervention technique which successfully treats one will equally successfully treat the rest of territories is a fallacy we have fallen for too many times. There are no shortcuts to knowledge: this is why ticagrelor continues to be controversial in strokes and practically incontrovertible in ACS.
This study recently published in Stroke carried out a systematic search of publications comparing ticagrelor against other P2Y12 receptor antagonist in combination with aspirin or against aspirin monotherapy to treat high risk cardio and cerebrovascular patients (CAD, ACS, strokes, transient ischemic attacks or peripheral vascular disease).
Efficacy end point was the occurrence of stroke and safety end point was bleeding and all-cause mortality.
The meta-analysis included 26 randomized studies with a total 124,495 patients.
Read also: HOST-EXAM: The Study that Challenges Aspirin as Long-Term Antiplatelet Therapy.
Compared against the control groups, ticagrelor combined with aspirin reduced stroke risk by 20%, with results significative (RR 0.80, CI 95%, 0.71 to 0.89). However, people receiving ticagrelor as monotherapy did not show this benefit so clearly (RR 0.88, CI 95%, 0.77 to 1.00; p=0.05).
All studies included a monotherapy branch (aspirin, ticagrelor, clopidogrel, etc.) that showed similar bleeding rate, while any combination increased bleeding by 100% vs. any monotherapy.
The combination of ticagrelor and aspirin did not offer benefits in terms of mortality.
Conclusion
The combination of ticagrelor and aspirin could bring benefits in terms of repeat events for patients with high risk of arteriosclerosis. The benefit of this combination in particular, as well as all other combinations, comes at the cost of increased bleeding, including intracranial bleeding.
Original Title: Network Meta-Analysis of Ticagrelor for Stroke Prevention in Patients at High Risk for Cardiovascular or Cerebrovascular Events.
Reference: Alexandra Bálint et al. Stroke. 2021 Aug;52(9):2809-2816. doi: 10.1161/STROKEAHA.120.032670.
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