Ticagrelor Versus Clopidogrel or Aspirin in Secondary Stroke Prevention: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND

Ticagrelor, a direct-acting P2Y12 receptor antagonist, has been proposed as an alternative to clopidogrel or aspirin for secondary prevention in patients with acute ischemic stroke or transient ischemic attack (TIA). However, its clinical utility remains uncertain due to variable trial findings and safety concerns. This study is aimed at evaluating the efficacy and safety of ticagrelor compared to clopidogrel or aspirin in reducing recurrent stroke and major bleeding in patients with noncardioembolic acute ischemic stroke or TIA.

METHODS

A systematic search of PubMed, Embase, CENTRAL, and Chinese databases was conducted to identify randomized controlled trials comparing ticagrelor with aspirin or clopidogrel in this population. The primary outcomes were recurrent stroke and major bleeding. Random-effects meta-analyses were performed, and heterogeneity was assessed using the I 2 statistic.

RESULTS

Six randomized controlled trials were included. Ticagrelor significantly reduced the risk of recurrent stroke compared to control (pooled OR: 0.78; 95% CI: 0.70-0.89; I 2 = 9%). No significant increase in major bleeding was observed (OR: 0.92; 95% CI: 0.66-1.28; I 2 = 0%). Risk of bias was low in two trials and raised some concerns in the remaining four due to open-label designs or limited reporting.

CONCLUSION

Ticagrelor offers superior efficacy over clopidogrel or aspirin in preventing recurrent stroke, with no excess risk of major bleeding. It may be particularly beneficial in patients with poor clopidogrel metabolism or high recurrence risk. Further research is needed to establish its long-term safety, cost-effectiveness, and optimal use in clinical practice.