Risk of acute myocardial infarction with ticagrelor, prasugrel, and clopidogrel prescription after coronary stent restenosis: A retrospective real-world comparative risk analysis with TriNetX.

BACKGROUND

Coronary stent restenosis remains a clinically significant challenge, often resulting in recurrent myocardial infarction (MI). Optimal antiplatelet therapy following restenosis is unclear, as most comparative studies were conducted in broader acute coronary syndrome populations.

METHODS

We conducted a retrospective cohort study using TriNetX to identify patients with in-stent restenosis (ICD-10: T82.855) who were subsequently prescribed clopidogrel, prasugrel, or ticagrelor. The primary outcome was acute MI (ICD-10: I21) within one year of prescription. Adjusted Cox proportional hazards models compared MI risk between agents, controlling for age, sex, HbA1c, heart failure, CKD, cerebrovascular disease, and mortality.

RESULTS

Among 40,206 patients, MI occurred in 22.5% of prasugrel users (n=1,139), 29.0% of clopidogrel users (n=35,071), and 35.9% of ticagrelor users (n=4,041). Compared to clopidogrel, ticagrelor was associated with significantly increased MI risk (HR 1.552; 95% CI: 1.467-1.642; p<0.001), while prasugrel showed no significant difference (HR 0.94; 95% CI: 0.835-1.057; p=0.3). Prasugrel was associated with significantly lower risk compared to ticagrelor (HR 0.589; 95% CI: 0.519-0.669; p<0.001).

CONCLUSIONS

In this real-world cohort of patients with coronary stent restenosis, ticagrelor was associated with a significantly higher 1-year MI risk compared to clopidogrel and prasugrel. These findings suggest potential differences in clinical outcomes among P2Y12 inhibitors in this high-risk setting and highlight the need for further prospective investigation to confirm these results.