1
|
Bonaca MP, Bhatt DL, Simon T, Fox KM, Mehta S, Harrington RA, Leiter LA, Capell WH, Held C, Himmelmann A, Ridderstråle W, Chen J, Lee JJ, Song Y, Andersson M, Prats J, Kosiborod M, McGuire DK, Steg PG. Limb Outcomes With Ticagrelor Plus Aspirin in Patients With Diabetes Mellitus and Atherosclerosis. J Am Coll Cardiol 2024; 83:1627-1636. [PMID: 38658101 DOI: 10.1016/j.jacc.2024.03.377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/26/2024] [Accepted: 03/05/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Ticagrelor reduced major adverse cardiovascular events (MACE) and increased bleeding in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease. Limb events including revascularization, acute limb ischemia (ALI), and amputation are major morbidities in patients with T2DM and atherosclerosis. OBJECTIVES This study sought to determine the effect of ticagrelor on limb events. METHODS Patients were randomized to ticagrelor or placebo on top of aspirin and followed for a median of 3 years. MACE (cardiovascular death, myocardial infarction, or stroke), limb events (ALI, amputation, revascularization), and bleeding were adjudicated by an independent and blinded clinical events committee. The presence of peripheral artery disease (PAD) was reported at baseline. RESULTS Of 19,220 patients randomized, 1,687 (8.8%) had PAD at baseline. In patients receiving placebo, PAD was associated with higher MACE (10.7% vs 7.3%; HR: 1.48; P < 0.001) and limb (9.5% vs 0.8%; HR: 10.67; P < 0.001) risk. Ticagrelor reduced limb events (1.6% vs 1.3%; HR: 0.77; 95% CI: 0.61-0.96; P = 0.022) with significant reductions for revascularization (HR: 0.79; 95% CI: 0.62-0.99; P = 0.044) and ALI (HR: 0.24; 95% CI: 0.08-0.70; P = 0.009). The benefit was consistent with or without PAD (HR: 0.80; 95% CI: 0.58-1.11; and HR: 0.76; 95% CI: 0.55-1.05, respectively; Pinteraction = 0.81). There was no effect modification of ticagrelor vs placebo based on PAD for MACE (Pinteraction = 0.40) or TIMI major bleeding (Pinteraction = 0.3239). CONCLUSIONS Patients with T2DM and atherosclerosis are at high risk of limb events. Ticagrelor decreased this risk, but increased bleeding. Future trials evaluating the combination of ticagrelor and aspirin would further elucidate the benefit/risk of such therapy in patients with PAD, including those without coronary artery disease. (A Study Comparing Cardiovascular Effects of Ticagrelor Versus Placebo in Patients With Type 2 Diabetes Mellitus [THEMIS]: NCT01991795).
Collapse
Affiliation(s)
- Marc P Bonaca
- University of Colorado, CPC Clinical Research, Aurora, Colorado, USA.
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Tabassome Simon
- Department of Clinical Pharmacology and Clinical Research, Research Platform of East of Paris (URCEST-CRCEST-CRB.APHPSU), Assistance Publique Hopitaux de Paris (APHP), Sorbonne Universite, FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Kim Michael Fox
- The National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London, United Kingdom
| | - Shamir Mehta
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | | | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Warren H Capell
- University of Colorado, CPC Clinical Research, Aurora, Colorado, USA
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Anders Himmelmann
- AstraZeneca BioPharmaceuticals R&D, Late-stage Development, Cardiovascular, Renal and Metabolic, Gothenburg, Sweden
| | - Wilhelm Ridderstråle
- AstraZeneca BioPharmaceuticals R&D, Late-stage Development, Cardiovascular, Renal and Metabolic, Gothenburg, Sweden
| | - Jersey Chen
- AstraZeneca BioPharmaceuticals R&D, Late-stage Development, Cardiovascular, Renal and Metabolic, Gothenburg, Sweden
| | - Jane J Lee
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Yang Song
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Marielle Andersson
- AstraZeneca BioPharmaceuticals R&D, Late-stage Development, Cardiovascular, Renal and Metabolic, Gothenburg, Sweden
| | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Ph Gabriel Steg
- French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148, Paris, France
| |
Collapse
|
2
|
Bonaca MP, Lesén E, Giannitsis E, Hedberg J, Jernberg T, Lambrelli D, Duong M, Maggioni AP, Ariza-Solé A, ten Berg J, Storey RF. Characteristics and outcomes in patients with a prior myocardial infarction treated with extended dual antiplatelet therapy with ticagrelor 60 mg: findings from ALETHEIA, a multi-country observational study. Eur Heart J Cardiovasc Pharmacother 2023; 9:701-708. [PMID: 37653447 PMCID: PMC10719500 DOI: 10.1093/ehjcvp/pvad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/17/2023] [Accepted: 08/29/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Guidelines recommend extended dual antiplatelet therapy, including ticagrelor 60 mg twice daily, in high-risk post-myocardial infarction (MI) patients who have tolerated 12 months and are not at high bleeding risk. The real-world utilization and bleeding and ischaemic outcomes associated with long-term ticagrelor 60 mg in routine clinical practice have not been well described. METHODS Register and claims data from the USA (Optum Clinformatics, IBM MarketScan, and Medicare) and Europe (Sweden, Italy, UK, and Germany) were extracted. Patients initiating ticagrelor 60 mg ≥12 months after MI, meeting eligibility criteria for the PEGASUS-TIMI (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin - Thrombolysis in Myocardial Infarction 45) 54 trial, were included. The cumulative incidence of the composite of MI, stroke, or all-cause mortality and that of bleeding requiring hospitalization were calculated. Meta-analyses were performed to combine estimates from each source. RESULTS A total of 7035 patients treated with ticagrelor 60 mg met eligibility criteria. Median age was 67 years and 29% were females; 12% had a history of multiple MIs. The majority (95%) had been treated with ticagrelor 90 mg prior to initiating ticagrelor 60 mg. At 12 months from initiation of ticagrelor 60 mg, the cumulative incidence [95% confidence interval (CI)] of MI, stroke, or mortality was 3.33% (2.73-4.04) and was approximately three-fold the risk of bleeding (0.96%; 0.69-1.33). CONCLUSIONS This study provides insights into the use of ticagrelor 60 mg in patients with prior MI in clinical practice. Observed event rates for ischaemic events and bleeding generally align with those in the pivotal trials, support the established safety profile of ticagrelor, and highlight the significant residual ischaemic risk in this population.Clinical Trials.gov Registration NCT04568083.
Collapse
Affiliation(s)
- M P Bonaca
- Department of Medicine, Cardiovascular Division, University of Colorado School of Medicine, Aurora, CO, USA
| | - E Lesén
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | | | - J Hedberg
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - T Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - D Lambrelli
- Real-World Evidence, Evidera Inc., London, UK
| | - M Duong
- Real-World Evidence, Evidera Inc., London, UK
| | - A P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
- Ricerca e Salute (ReS) Foundation, Rome, Italy
| | - A Ariza-Solé
- Bellvitge University Hospital, Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- University Medical School Maastricht, Maastricht, The Netherlands
| | - R F Storey
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK and NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
3
|
Bonaca MP, Im K, Magnani G, Bansilal S, Dellborg M, Storey RF, Bhatt DL, Steg PG, Cohen M, Johanson P, Braunwald E, Sabatine MS. Patient selection for long-term secondary prevention with ticagrelor: insights from PEGASUS-TIMI 54. Eur Heart J 2022; 43:5037-5044. [PMID: 36367709 DOI: 10.1093/eurheartj/ehac402] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 04/20/2022] [Accepted: 07/12/2022] [Indexed: 11/12/2022] Open
Abstract
AIM In patients with prior myocardial infarction (MI) on aspirin, the addition of ticagrelor reduces ischaemic risk but increases bleeding risk. The simultaneous assessment of baseline ischaemic and bleeding risk may assist clinicians in selecting patients who are most likely to have a favourable risk/benefit profile with long-term ticagrelor. METHODS AND RESULTS PEGASUS-TIMI 54 randomized 21 162 prior MI patients, 13 956 of which to the approved 60 mg dose or placebo and who had all necessary data. The primary efficacy endpoint was cardiovascular death, MI, or stroke, and the primary safety outcome was TIMI major bleeding; differences in Kaplan-Meier event rates at 3 years are presented. Post-hoc subgroups based on predictors of bleeding and ischaemic risk were merged into a selection algorithm. Patients were divided into four groups: those with a bleeding predictor (n = 2721, 19%) and then those without a bleeding predictor and either 0-1 ischaemic risk factor (IRF; n = 3004, 22%), 2 IRF (n = 4903, 35%), or ≥3 IRF (n = 3328, 24%). In patients at high bleeding risk, ticagrelor increased bleeding [absolute risk difference (ARD) +2.3%, 95% confidence interval (CI) 0.6, 3.9] and did not reduce the primary efficacy endpoint (ARD +0.08%, 95% CI -2.4 to 2.5). In patients at low bleeding risk, the ARDs in the primary efficacy endpoint with ticagrelor were -0.5% (-2.2, 1.3), -1.5% (-3.1, 0.02), and -2.6% (-5.0, -0.24, P = 0.03) in those with ≤1, 2, and 3 risk factors, respectively (P = 0.076 for trend across groups). There were significant trends for greater absolute risk reductions for cardiovascular death (P-trend 0.018), all-cause mortality (P-trend 0.027), and net outcomes (P-trend 0.037) with ticagrelor across these risk groups. CONCLUSION In a post-hoc exploratory analysis of patients with prior MI, long-term ticagrelor therapy appears to be best suited for those with prior MI with multiple IRFs at low bleeding risk. CLINICAL TRIAL REGISTRATION NCT01225562 ClinicalTrials.gov.
Collapse
Affiliation(s)
- Marc P Bonaca
- Department of Cardiology and Vascular Medicine, University of Colorado School of Medicine, 2115 N Scranton St Suite 2040, Aurora, CO 80045, USA
| | - KyungAh Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Mikael Dellborg
- Department of Medicine/Östra, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P Gabriel Steg
- Université Paris-Cité, INSERM U-1148 and AP-HP, Hôpital Bichat, FACT (French Alliance for Cardiovascular Trials) Paris, France
| | - Marc Cohen
- Newark Beth Israel Medical Center, Rutgers Medical School, Newark, New Jersey, USA
| | | | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|