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Ticagrelor Compared with Clopidogrel in Acute Coronary Syndrome and Stable Coronary Artery Disease

 

Am Fam Physician. 2019 Nov 1;100(9):online.

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Details for This Review

Study Population: Patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI)

Efficacy End Points: Death, heart attack, stroke

Harm End Points: Major bleeding, dyspnea

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TICAGRELOR (BRILLINTA) COMPARED WITH CLOPIDOGREL (PLAVIX) IN PATIENTS WITH ACUTE CORONARY SYNDROME AND STABLE CORONARY ARTERY DISEASE

BenefitsHarms

No patients were helped

1 in 166 patients had a major bleeding event

1 in 13 patients developed dyspnea

TICAGRELOR (BRILLINTA) COMPARED WITH CLOPIDOGREL (PLAVIX) IN PATIENTS WITH ACUTE CORONARY SYNDROME AND STABLE CORONARY ARTERY DISEASE

BenefitsHarms

No patients were helped

1 in 166 patients had a major bleeding event

1 in 13 patients developed dyspnea

Narrative: Dual antiplatelet therapy (aspirin plus clopidogrel [Plavix] or ticagrelor [Brillinta]) compared with aspirin alone after PCI modestly reduces nonfatal events such as heart attack and stroke.1,2 This finding has led some to believe that better antiplatelet agents could improve outcomes further; ticagrelor has been proposed as such an agent.

The systematic review summarized here included 11 trials and five observational studies that enrolled a total of 25,805 patients with ACS undergoing PCI and those with stable coronary artery disease.3 The patients included were predominantly men, with a mean age of 54 to 72 years. The trials enrolled patients from the United States, United Kingdom, Japan, Korea, Spain, Italy, France, Taiwan, and China.

Ticagrelor, compared with clopidogrel, did not reduce heart attacks, strokes, deaths, or stent thrombosis, but it did increase major bleeding (absolute risk difference [ARD] = 0.6%; odds ratio [OR] = 1.52; 95% CI, 1.01 to 2.29; number needed to harm [NNH] = 166). Major bleeding was defined as a significant drop in hemoglobin (> 3 g per dL [30 g per L]) or requiring blood transfusion, or intraocular bleeding resulting in vision loss or complete blindness.3

More patients in the ticagrelor group experienced dyspnea (ARD = 7.6%; OR = 2.64; 95% CI, 1.87 to 3.72; NNH = 13), which could be one reason why there was a significantly higher rate of drug discontinuation among patients in this group (ARD = 1.7%; OR =

Author disclosure: No relevant financial affiliations.


Copyright © 2019 MD Aware, LLC (theNNT.com). Used with permission.

This series is coordinated by Dean A. Seehusen, MD, MPH, AFP Assistant Medical Editor, and Daniel Runde, MD, from the NNT Group.

A collection of Medicine by the Numbers published in AFP is available at https://www.aafp.org/afp/mbtn.

References

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1. Bowry AD, Brookhart MA, Choudhry NK. Meta-analysis of the efficacy and safety of clopidogrel plus aspirin as compared to antiplatelet monotherapy for the prevention of vascular events. Am J Cardiol. 2008;101(7):960–966....

2. Newman D. Clopidogrel added to aspirin during and after a coronary event or a stent procedure. Accessed March 16, 2019. http://www.thennt.com/nnt/clopidogrel-added-to-aspirin-during-and-after-a-coronary-event-or-stenting/

3. Guan W, Lu H, Yang K. Choosing between ticagrelor and clopidogrel following percutaneous coronary intervention: a systematic review and meta-analysis (2007–2017). Medicine (Baltimore). 2018;97(43):e12978.

4. Wallentin L, Becker RC, Budaj A, et al.; PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045–1057.

5. Goto S, Huang CH, Park SJ, et al. Ticagrelor vs. clopidogrel in Japanese, Korean and Taiwanese patients with acute coronary syndrome—randomized, double-blind, phase III PHILO study. Circ J. 2015;79(11):2452–2560.

6. Goodrx.com. Antiplatet drugs. Accessed March 16, 2019. https://www.goodrx.com/antiplatelet-drugs

7. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10):1082–1115.

 

 

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