Switching from ticagrelor to clopidogrel: New answers and further questions

De-escalation therapy after acute coronary syndrome: is it reasonable to switch from prasugrel (or ticagrelor) to clopidogrel early?

Dual antiplatelet treatment (DAPT) is the treatment of choice to prevent atherothrombotic events in patients with acute coronary syndrome (ACS) treated with percutaneous interventions (PCIs). The availability of different P2Y12 inhibitors set the stage for costum made DAPT, as to achieve the highest profile of safety and efficacy. The de-escalation therapy for the newer and more powerful antiplatelet drugs, such as ticagrelor and prasugrel, to clopidogrel, is a strategy for patients with recent ACS, unfit for continuing DAPT for their high risk of bleeding, or side effects, or socio-economic reasons, but without a prohibitive ischaemic risk. There is a need for compelling clinical evidences able to provide the clinical cardiologist with the necessary information to decide the best antiplatelet strategy for each individual patient.

Switching from ticagrelor to clopidogrel in patients with ST-segment elevation myocardial infarction undergoing successful percutaneous coronary intervention in real-world China: Occurrences, reasons, and long-term clinical outcomes

BACKGROUND

Although switching between ticagrelor and clopidogrel is common in clinical practice, the efficacy and safety of this de-escalation remain controversial.

HYPOTHESIS

We assessed the occurrences, reasons, and outcomes of switching from ticagrelor to clopidogrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing successful primary percutaneous coronary intervention (PCI).

METHODS

A total of 653 patients with STEMI were randomly assigned to receive loading dose of ticagrelor or clopidogrel before PCI and then received maintenance dose, respectively, for 12 months follow-up. The primary outcome was major adverse cardiac events (MACE), including cardiovascular death, nonfatal myocardial infarction, and stroke. The secondary outcome included unexpected rehospitalization for angina, coronary revascularization, and stent thrombosis. The safety outcome was bleeding described by the Bleeding Academic Research Consortium (BARC) criteria.

RESULTS

A total of 602 participants completed the study. The rate of switching from ticagrelor to clopidogrel was 48.6% and the main reason was financial burden. The rate of secondary ischemic events in the de-escalation group was higher than that in the ticagrelor group (15.1% vs 5.6%, P = 0.008), but lower than that in the clopidogrel group (15.1% vs 24.6%, P = 0.03), while there were no significant differences in MACE among the three groups (P = 0.16). De-escalation, ticagrelor, and clopidogrel did not cause significant differences in the rates of major bleeding among the three groups (BARC ≥ 2, P = 0.34).

CONCLUSION

Switching from ticagrelor to clopidogrel is very common in patients with STEMI in China. De-escalation might be safe but associated with high risk of ischemic events as compared to ticagrelor.