Comparison of in-hospital net clinical outcomes of ticagrelor and clopidogrel in acute coronary syndrome patients stratified by CRUSADE score: findings from the CCC-ACS registry

OBJECTIVES: To compare the effect of ticagrelor and clopidogrel on net clinical outcomes in patients with acute coronary syndrome (ACS) and assess the CRUSADE score's utility in guiding the selection of P2Y12 inhibitors. DESIGN: Nationwide observational cohort study using data from the CCC-ACS registry. SETTING: About 159 tertiary hospitals and 82 secondary hospitals across China. PARTICIPANTS: About 70,319 patients with ACS who were prescribed dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor within 24 h of the first medical contact. Inclusion criteria were based on ACS diagnosis, and exclusion criteria included coronary artery bypass grafting, thrombolysis, use of oral anticoagulants, atrial fibrillation, or incomplete data. MAIN OUTCOME MEASURES: Primary endpoint was in-hospital net adverse clinical events (NACE) defined as the composite of all-cause mortality, major ischemic events (recurrent myocardial infarction, stent thrombosis, ischemic stroke), and major bleeding (BARC types 3b, 3c, 5). Secondary endpoints included all-cause mortality, major ischemic events, major bleeding, intracranial bleeding, and major adverse cardiovascular events (MACE). RESULTS: After propensity score matching, no significant difference was found in NACE (1.6% in both groups; OR 0.97, 95% CI 0.82 to 1.16, p = .74) or all-cause mortality (0.7% in both groups; OR 0.92, 95% CI 0.71 to 1.20, p = .55) between ticagrelor and clopidogrel. However, ticagrelor was associated with significantly lower risks of MACE (1.0% vs. 1.2%; OR 0.80, 95% CI 0.65 to 0.99, p = .04) and major ischemic events (0.4% vs. 0.5%; OR 0.70, 95% CI 0.51 to 0.96, p = .03), but higher risks of major bleeding (1.6% vs. 1.1%; OR 1.50, 95% CI 1.24 to 1.81, p < .001), intracranial bleeding (0.3% vs. 0.1%; OR 2.24, 95% CI 1.35 to 3.72, p = .002), and gastrointestinal bleeding (0.9% vs. 0.5%; OR 1.74, 95% CI 1.33 to 2.28, p < .001). The CRUSADE score significantly interacted with the impact of P2Y12 inhibitor choice on clinical outcomes. In those with a CRUSADE score >40, ticagrelor was linked to higher risks of NACE (p = .03) and all-cause mortality (p = .04), while lower CRUSADE scores (