• Intern Emerg Med · Mar 2021

    Multicenter Study

    Clopidogrel versus ticagrelor in high-bleeding risk patients presenting with acute coronary syndromes: insights from the multicenter START-ANTIPLATELET registry.

    • Felice Gragnano, Elisabetta Moscarella, Paolo Calabrò, Arturo Cesaro, Pia Clara Pafundi, Alfonso Ielasi, Giuseppe Patti, Ilaria Cavallari, Emilia Antonucci, Plinio Cirillo, Pasquale Pignatelli, Gualtiero Palareti, Francesco Pelliccia, Carlo Gaudio, Ferdinando Carlo Sasso, Vittorio Pengo, Paolo Gresele, Rossella Marcucci, and START-ANTIPLATELET Collaborators.
    • Division of Clinical Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", 81100, Caserta, Italy.
    • Intern Emerg Med. 2021 Mar 1; 16 (2): 379-387.

    AbstractOptimal dual antiplatelet therapy (DAPT) strategy in high-bleeding risk (HBR) patients presenting with acute coronary syndrome remains debated. We sought to investigate the use of clopidogrel versus ticagrelor in HBR patients with acute coronary syndrome and their impact on ischemic and bleeding events at 1 year. In the START-ANTIPLATELET registry (NCT02219984), consecutive patients with ≥ 1 HBR criteria were stratified by DAPT type in clopidogrel versus ticagrelor groups. The primary endpoint was net adverse clinical endpoints (NACE), defined as a composite of all-cause death, myocardial infarction, stroke, and major bleeding. Of 1209 patients with 1-year follow-up, 553 were defined at HBR, of whom 383 were considered eligible for the study as on DAPT with clopidogrel (174 or 45.4%) or ticagrelor (209 or 54.6%). Clopidogrel was more often administered in patients at increased ischemic and bleeding risk, while ticagrelor in those undergoing percutaneous coronary intervention. Mean DAPT duration was longer in the ticagrelor group. At 1 year, after multivariate adjustment, no difference in NACEs was observed between patients on clopidogrel versus ticagrelor (19% vs. 11%, adjusted hazard ratio 1.27 [95% CI 0.71-2.27], p = 0.429). Age, number of HBR criteria, and mean DAPT duration were independent predictors of NACEs. In a real-world registry of patients with acute coronary syndrome, 45% were at HBR and frequently treated with clopidogrel. After adjustment for potential confounders, the duration of DAPT, but not DAPT type (stratified by clopidogrel vs. ticagrelor), was associated with the risk of ischemic and bleeding events at 1 year.

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