Authors
Wallentin L, Becker R, Budaj A, et al.
Title
Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes
References
N Engl J Med 2009;361:1045-1057.
Background
Clopidogrel in combination with ASA is the standard of care for acute coronary syndrome (ACS) and/or percutaneous coronary intervention to reduce the risk of ischemic complications and stent thrombosis respectively. Ticagrelor is an oral, reversible antiplatelet agent that has a more rapid onset and a more pronounced and consistent antiplatelet effect than clopidogrel.
Purpose
To determine whether ticagrelor is superior to clopidogrel for the prevention of vascular events and death in patients with acute coronary syndrome.
Design
  • Multicenter, randomized, double-blind study
  • 18, 624 patients presenting with ACS (with or without ST-segment elevation) within 24 hours of symptom onset.
Exclusion Criteria
None.
Follow-Up
12 months (mean: 9.2 months)
Treatment Regimen
  • Clopidogrel 300 mg po x 1 dose (additional 300 mg allowed at investigator’s discretion), then 75 mg once daily x 6-12 months versus
  • Ticagrelor 180 mg po x 1 dose, then 90 mg po bid x 6-12 months. An additional 90 mg was given in patients undergoing PCI more than 24 hours after randomization.
  • Everyone received Aspirin 75-100 mg po daily.
Results
Ticagrelor significantly decreased the primary endpoint: death from vascular cause/MI/stroke, with no significant difference in major bleeding (primary safety endpoint).

Ticagrelor significantly decreased the risk of several secondary endpoints, including death from vascular cause, non-fatal MI, stent thrombosis (1.3% vs 1.9%, p=0.009) and all-cause mortality.

Ticagrelor was associated with a higher rate of major bleeding not related to coronary artery bypass grafting (2.8% vs 2.2%, p=0.03), including intracranial fatal bleeding.
Summary
When compared with clopidogrel, ticagrelor significantly reduced the composite endpoint of death from vascular causes, myocardial infarction, or stroke. Although it did not demonstrate an increased risk in overall major bleeding, there was an increased rate of non-CABG bleeding. Ticagrelor significantly decreased stent thrombosis and all-cause mortality.
Implications
None.
Related Figures
[1, 2, 3, 4]