Ticagrelor versus clopidogrel in orally anticoagulated patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND: inhibitor strategies in this setting is limited. AIMS: This study aimed to compare outcomes with ticagrelor versus clopidogrel as part of dual antithrombotic treatment in ACS patients undergoing PCI. METHODS: Using data from the SWEDEHEART registry, we conducted a cohort study including patients on dual antithrombotic treatment with ACS undergoing PCI between January 2014 and February 2022. Outcomes within one year were analysed using multivariate Cox regression to obtain adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for major adverse cardiovascular events (MACE; including mortality, myocardial infarction [MI], and stroke), all-cause mortality, clinically relevant bleeding, and MI. RESULTS: A total of 3,708 patients were included (median age 76 years; 69% males; 40% ST-segment elevation myocardial infarction). At discharge, 1,170 (32%) received ticagrelor and 2,538 (68%) clopidogrel. For MACE, the unadjusted event rate was 16.7% in the ticagrelor group and 16.6% in the clopidogrel group (aHR 1.02, 95% CI: 0.84-1.23). Mortality occurred in 6.6% of patients treated with ticagrelor and 6.2% of those treated with clopidogrel (aHR 1.24, 95% CI: 0.91-1.69). Bleeding was 4.9% in the ticagrelor group compared with 3.7% in the clopidogrel group (aHR 1.53, 95% CI: 1.06-2.22). MI occurred in 10.4% of patients on ticagrelor and 11.2% of those on clopidogrel (aHR 0.90, 95% CI: 0.71-1.13). CONCLUSIONS: In ACS patients on DOACs undergoing PCI, ticagrelor was associated with an increased risk of bleeding compared with clopidogrel, with no differences in MACE, mortality, or MI.