[Efficacy and safety of ticagrelor versus clopidogrel after percutaneous coronary intervention in patients with acute coronary syndrome without standard modifiable cardiovascular risk factors].

Objective

To evaluate the efficacy and safety of ticagrelor versus clopidogrel in real-world patients with acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors (SMuRF-less) following percutaneous coronary intervention (PCI).

Methods

This retrospective cohort study was based on a single-center, prospective PCI registry. SMuRF-less ACS patients (defined as the concurrent absence of hypertension, diabetes mellitus, hyperlipidemia, and current smoking at admission) who underwent PCI at the General Hospital of Northern Theater Command between March 2016 and March 2023 were consecutively enrolled. Patients were categorized into clopidogrel and ticagrelor groups based on the P2Y12 receptor inhibitor prescribed at discharge. The primary efficacy endpoint was major adverse cardiovascular events at 12 months, defined as a composite of cardiac death, myocardial infarction, or ischemic stroke. The primary safety endpoint was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding. Multivariable Cox proportional hazards regression models were used to compare outcomes between the two groups.

Results

A total of 3 323 SMuRF-less ACS patients were included (age (61.8±10.6) years; 1 120 (33.7%) female), comprising 2 694 (81.1%) in the clopidogrel group and 629(18.9%) in the ticagrelor group. Compared with the clopidogrel group, the ticagrelor group had a higher proportion of acute myocardial infarction, younger age, a higher proportion of males, and higher estimated glomerular filtration rate and hemoglobin levels (all P<0.05). During the 12-month follow-up, the incidence of the primary efficacy endpoint, major adverse cardiovascular events, did not differ significantly between the ticagrelor and clopidogrel groups (1.4% (9/629) vs. 2.0% (55/2 694), HR=0.90, 95%CI: 0.43-1.87, P=0.778). However, the ticagrelor group had a significantly higher incidence of the primary safety endpoint, Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, compared with the clopidogrel group (9.2% (58/629) vs. 5.9% (160/2 694), HR=1.79, 95%CI: 1.30-2.47, P<0.001).

Conclusions

Among SMuRF-less ACS patients undergoing PCI, ticagrelor did not reduce ischemic events compared with clopidogrel, but was associated with a significantly higher bleeding risk. Clopidogrel may represent a more appropriate P2Y₁₂ receptor inhibitor for this population.