Ticagrelor Trumps Clopidogrel in ACS Patients Slated for Noninvasive Management

The results of yet another prespecified subgroup analysis mimic those of the larger trial.

Note: Ticagrelor has now been approved by the FDA for marketing in the U.S. For a discussion of the response to this approval in the cardiology community, see the recent Voices blog on CardioExchange, an online forum for cardiology news and discussion.


In the PLATO trial, which involved more than 18,000 patients with acute coronary syndromes (ACS), ticagrelor produced a greater reduction in the risk for ischemic events and death than clopidogrel did, without increasing the risk for major bleeding. This result held true both in the overall study population (JW Cardiol Sep 2 2009) and in the patients initially slated for invasive treatment (JW Cardiol Feb 17 2010), but what about those slated for noninvasive treatment?

Researchers conducted a prespecified analysis of ticagrelor versus clopidogrel among the 5216 study participants (median age, 65; 37% women) whose physicians indicated, prior to randomization, that they would be managed noninvasively. Notably, only 60% of these patients were managed as planned; during initial hospitalization, 42% underwent coronary angiography, 20% underwent percutaneous coronary intervention, and 4% underwent coronary artery bypass grafting.

Ticagrelor once again outperformed clopidogrel, with lower rates of both the primary outcome (cardiovascular death, myocardial infarction, or stroke; 12.0% vs. 14.3%; P=0.04) and all-cause mortality (6.1% vs. 8.2%; P=0.01). Rates of major bleeding were slightly, but not significantly, higher with ticagrelor (11.9% and 10.3%; P=0.08).


Citation(s):

James SK et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: Substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial. BMJ 2011 Jun 17; 342:d3527.

Timmis A. Non-interventional management of acute coronary syndromes. BMJ 2011 Jun 17; 342:d3263.