(AM) Comparative Effectiveness of Ticagrelor, Prasugrel, and Clopidogrel for Secondary Prophylaxis in Acute Coronary Syndrome

Friday, August 26, 2022

8:00 AM – 6:00 PM CEST

Location: Hall E South

Publication Number: 329

Presenting Author(s)

Joel F. Farley, PhD
– University of Minnesota College of Pharmacy, Minneapolis, Minnesota, United States

Co-Author(s)

Arun Kumar, PharmD, PhD, MS, BPharm
– University of Cincinnati College of Pharmacy, University of Cincinnati College of Pharmacy, Cincinnati, Ohio, United States
Pamela Lutsey, PhD
– Associate Professor, Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN 55454, USA, MN, United States
Wendy St Peter, PharmD, FCCP, FASN, FNKF
– Professor, Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA, Minneapolis, MN, United States
Jon Schommer, PhD
– Professor, Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA, Minneapolis, MN, United States
Jeremy Van’t Hof, MD, MS
– Assistant Professor of Medicine, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN 55455, USA, Minneapolis, MN, United States
Abhijeet Rajpurohit, MS, BDS
– Data Analyst/Researcher, Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA, Minneapolis, MN, United States

Background: Real-world evidence of the comparative effectiveness of newer P2Y12 inhibitors (prasugrel and ticagrelor) compared to clopidogrel in acute coronary syndrome (ACS) is limited in US populations.

Objectives: This study aims to evaluate the comparative effectiveness of each P2Y12 inhibitor on cardiovascular outcomes overall and within subgroups by sex, type of stent, and ACS presentation in a real-world patient setting.

Methods: This retrospective matched-cohort study used data from IBM MarketScan, a U.S. administrative claims database (2013-2018). We used propensity score matching to create 3 paired cohorts for analysis: ticagrelor vs. clopidogrel (N=21,719), prasugrel vs. clopidogrel (N=11,513), and prasugrel vs. ticagrelor (N=11,065). The primary outcome variable was a composite cardiovascular event including recurrent myocardial infarction or unstable angina, revascularizations, ischemic or hemorrhagic stroke or transient ischemic attacks, and heart failure events. These groups were compared in a time-to-event analysis for primary short-term effectiveness at 30, 90, and 180 days following the first prescription of a P2Y12 inhibitor after percutaneous coronary intervention (PCI).

Results: Compared with clopidogrel, ticagrelor use was associated with a 10% reduction in the primary composite outcome at 90 days (HR 0.90, 95% CI 0.82 0.99). There were no other significant differences in short-term outcomes for any other matched pairs. In the subgroup analysis of females, there was an associated risk reduction of 27% for prasugrel at 30 days (HR 0.73, 95% CI 0.53 1.00) and 17% for ticagrelor at 90 days (HR 0.83, 95% CI 0.70 0.98) when compared to clopidogrel. Finally, among patients managed with bare-metal stents, prasugrel use was associated with a 55% and 33% reduced risk for primary outcome compared to ticagrelor at 30 days (HR 0.45, 95% CI 0.25 0.82) and 180 days (HR 0.67, 95% CI 0.46 0.98), respectively.

Conclusions: This study showed little difference in short-term cardiovascular outcomes based on P2Y12 inhibitor choice after PCI and may help inform clinicians when choosing between these medications.