Introduction: Ticagrelor or prasugrel are increasingly used in acute coronary syndrome (ACS) patients. We compared prescription rate, bleeding and outcomes after ticagrelor, prasugrel or clopidogrel use in ACS patients following percutaneous coronary intervention (PCI).
Methods: From 9684 ACS patients who underwent PCI in a recent nationwide registry, we anaylzed prescription rates, bleeding and major adverse cardiac events (MACE; cardiac death, myocardial infarction, stroke) according to ticagrelor, prasugrel or clopidogrel use.
Results: Prescription rates were 15.2% in ticagrelor (n=1474), 11.7% in prasugrel (n=1137) and 73.0% in clopidogrel (n=7073). Bleeding occurred in 565 patients (5.8%) with 108 patient (7.3%) in ticagrelor, 80 patients (7.9%) in prasugrel and 377 patients (5.3%) in clopidogrel. Compared to clopidogrel group, bleeding rates were significantly higher in ticagrelor (p=0.008) and prasugrel (p=0.012) groups, but not different between ticagrelor and prasugrel groups in entire (p=0.129) and propensity score (PS)-matched cohorts (n=1052, 7.6% vs. 7.6%, p=0.581; odds ratio 0.69, 95% confidence interval [CI] 0.23-2.05, p=0.505). MACE occurred in 804 patients (8.3%) during mean follow-up of 468 days. MACE-free survival rates were significantly lower in clopidogrel group than ticagrelor (90.8% vs. 94.4%, log rank p=0.001) or prasugrel groups (90.8% vs. 93.9%, log rank p=0.001), but not different between ticagrelor and prasugrel groups (entire: 94.4% vs. 93.9%, log rank p=0.234; PS-matched: 94.7% vs. 93.7%, log rank p=0.109). The use of ticagrelor (hazard ratio [HR] 0.66, 95% CI 0.52-0.85, p=0.001) or prasugrel (HR 0.65, 95% CI 0.51-0.84, p=0.001) were associated with lower risk of MACE than clopidogrel use, whereas there was no significant difference in risk of MACE between ticagrelor and prasugrel use (entire: HR 0.81, 95% CI 0.58-1.14, p=0.235; PS-matched: HR 0.39, 95% CI 0.12-1.29, p=0.123).
Conclusions: In a real-world registry of ACS patient who underwent PCI, ticagrelor or prasugrel were not in higher prescriptions but improved outcomes significantly with more frequent bleeding events than clopidogrel. In addition, bleeding rates and clinical outcomes were similar between ticagrelor and prasugrel use.