Ticagrelor Versus Clopidogrel in Patients With ST-Elevation Myocardial Infarction and Elevated Platelet Counts: A Multicenter Comparative Analysis of Ischemic Outcomes.

BACKGROUND

Dual antiplatelet therapy is essential for managing ST-elevation myocardial infarction (STEMI); however, the optimal choice of P2Y12 inhibitor in patients with thrombocytosis remains unclear. Therefore, this study aimed to compare the effects of clopidogrel and ticagrelor on the prognosis of patients with STEMI and platelet counts exceeding 350 × 109/L.

METHODS

Utilizing data from the Tianjin Health and Medical Big Data platform (2010-2023), this retrospective cohort study included patients with acute myocardial infarction from 82 hospitals. After propensity score matching, 461 patients were assigned to two groups: ticagrelor and clopidogrel. Kaplan-Meier curves and Cox regression analyses were employed to evaluate outcomes, with major adverse cardiac and cerebrovascular events (MACCEs) as the primary outcome. Secondary outcomes included net adverse clinical events (NACEs), all-cause mortality, cardiac mortality, recurrent non-fatal myocardial infarction, coronary revascularization, cerebral infarction, and bleeding events (Bleeding Academic Research Consortium (BARC) types 3-5). A MACCE was defined as a composite of cardiac mortality, recurrent non-fatal myocardial infarction, and cerebral infarction, while a NACE encompassed a MACCE plus bleeding events (BARC types 3-5).

RESULTS

Ticagrelor significantly reduced MACCEs (6.9% versus 12.1%; p = 0.008), all-cause mortality (3.9% versus 9.5%; p < 0.001), cardiac mortality (3.5% versus 7.4%; p = 0.0096), and NACEs (8.2% versus 13.0%; p = 0.021) compared with clopidogrel. Exploratory multivariable analysis confirmed an independent association of ticagrelor with reduced risks of MACCEs (adjusted hazard ratio (aHR) = 0.59; 95% confidence interval (CI), 0.37-0.93), NACEs (aHR = 0.64; 95% CI, 0.42-0.98), and all-cause mortality (aHR = 0.47; 95% CI, 0.26-0.83).

CONCLUSIONS

Ticagrelor was associated with superior clinical outcomes in patients with STEMI and elevated admission platelet counts (≥350 × 109/L) compared with clopidogrel. In contrast to genetic testing, which is costly, time-consuming (≥24-72 hours), and impractical in emergencies, this simple, universally available platelet count threshold offers an immediate, practical biomarker for selecting potent P2Y12 inhibition in acute settings.