Abstract
BACKGROUND: Ticagrelor is recommended as the preferred antiplatelet agent for patients with acute coronary syndrome (ACS), which is controversial in East Asians, Chinese patients in particular. This study aimed to compare the efficacy and safety of ticagrelor vs. clopidogrel in Chinese ACS patients following coronary stenting. METHODS: Between August 2014 and October 2020, COSTIC recruited 9,040 patients prescribed with ticagrelor or clopidogrel. Applying propensity score matching, ticagrelor was compared with clopidogrel for 1-year risks of the primary efficacy endpoint (a composite of cardiovascular (CV) death, myocardial infarction and stroke) and bleeding endpoint. RESULTS: The risk of the primary efficacy endpoint was comparable between the two groups but numerically higher after clopidogrel at 6 months (HR, 1.33 [95 % CI, 0.98-1.80]; P = 0.07). Clopidogrel was associated with high incidences of CV death (HR, 1.49 [95 % CI, 1.04-2.15]; P = 0.03 at 6 months; HR, 1.42 [95 % CI, 1.04-1.93]; P = 0.02 at 12 months) and all-cause death (HR, 1.43 [95 % CI, 1.02-1.99]; P = 0.04 at 6 months). BARC type 3 or 5 bleeding (OR, 0.60 [95 % CI, 0.40-0.88]; P = 0.008 at 6 months; OR, 0.71 [95 % CI, 0.52-0.96]; P = 0.03 at 12 months) and BARC type 2 bleeding risks (OR, 0.47 [95 % CI, 0.34-0.66] at 1 month, OR, 0.41 [95 % CI, 0.32-0.52] at 6 months, OR, 0.43 [95 % CI, 0.35-0.53] at 12 months, P < 0.001 at 1, 6 and 12 months) were higher with ticagrelor, as compared to clopidogrel. In terms of the net clinical benefit events, clopidogrel was comparable to ticagrelor in the total cohort. CONCLUSIONS: Among Chinese ACS patients with successful PCI, ticagrelor did not significantly reduce the risk of major ischemic events; instead, it was associated with a significant elevation bleeding risk.