Comparison Between Ticagrelor And Clopidogrel In Elderly Patients Undergoing Percutaneous Coronary Intervention

Objective:Dual antiplatelet therapy is the standard medication regimen for patients with coronary heart disease after Percutaneous Coronary Intervention(PCI).While antiplatelet therapy reduces the risk of ischemia,it also increases the risk of bleeding,and bleeding events will affect the prognosis of patients.Age is a strong predictor of adverse outcomes in patients with coronary artery disease undergoing PCI both for a higher risk of bleeding and ischemia.Elderly patients undergoing PCI tend to have more comorbidities and coexisting risk factors and are at higher risk of recurrent ischemic events and death,as well as treatment-related complications compared with younger patients.Previous studies have shown that ticagrelor,as a new P2Y₁₂ receptor inhibitor,has a stronger platelet inhibitory effect that reduces ischemic events and increases the occurrence of major bleeding.Although elderly patients represent the fastest-growing patient subgroup undergoing PCI,they tend to be underrepresented in randomized trials.The purpose of this study is to investigate the safety and efficacy of ticagrelor in elderly patients with coronary heart disease receiving PCI.Methods:Patients over 75 years of age admitted to the First Affiliated Hospital of Dalian Medical University From January 1,2015 to December 31,2019 who have successfully undergone PCI and received dual antiplatelet therapy based on aspirin and P2Y₁₂ receptor inhibitors were included in our study.The clinical data was retrospectively analyzed and divided into clopidogrel group and ticagrelor group according to the P2Y₁₂receptor inhibitor scheme in the dual antiplatelet therapy.The patients were followed up in outpatient clinics or by telephone,and the follow-up time was up to 1 year after the dual antiplatelet therapy after discharge from the hospital,and the occurrence of endpoint events was recorded.The primary safety endpoint of the study was type2,3,5,bleeding as defined by Bleeding Academic Research Consortium(BARC),and the primary efficacy endpoint was the combined major adverse cardiovascular and cerebrovascular events(MACCEs)including all-cause death,myocardial infarction,ischemic stroke,and any revascularization.COX proportional hazard model and propensity score matching(PSM)were used to correct confounding factors to accurately assess its safety and effectiveness endpoints and analyze the related risk factors of MACCEs and bleeding in elderly patients after PCI.Results:A total of 1505 patients were enrolled in this study,including 442 patients in the ticagrelor group and 1063 patients in the clopidogrel group.Compared with the ticagrelor group,the clopidogrel group had a higher proportion of women,a lower level of e GFR,hemoglobin and LVEF and were more complicated with a history of hypertension,ischemic stroke,atrial fibrillation/atrial flutter,gastrointestinal diseases,prior bleeding history.While there was a higher rate of left main diseases in the ticagrelor group.Compared with clopidogrel,the 12-month MACCEs(HR 0.957,95%CI 0.702-1.305,p=0.782)and its independent endpoints(all-cause death,myocardial infarction,revascularization,ischemic stroke)were not different between the two groups.The incidence of BARC2,3,5 bleeding(HR 2.304,95%CI 1.540-3.447,p<0.001),PLATO major bleeding and minor bleeding(HR 2.296,95%CI 1.522-3.464,p<0.001),any bleeding(HR 2.476 95%CI 1.802-3.403,p<0.001)in ticagrelor group was significantly higher than that of clopidogrel group.However,there was no significant difference between the two groups in BARC3,5 bleeding(HR 1.566 95%CI 0.767-3.198,p=0.218),TIMI major bleeding and minor bleeding.Old myocardial infarction,ischemic stroke,peripheral artery disease,e GFR and multi-vessel disease were independent risk factors of MACCEs.The application of ticagrelor,prior bleeding history and malignant tumor were related to the increased risk of type2,3 and 5 bleeding as defined by BARC.Conclusion:Compared with clopidogrel,dual antiplatelet therapy based on ticagrelor significantly increased the risk of BARC2,3 and 5 bleeding without reducing MACCEs in elderly patients who received PCI.In clinical practice,accurate risk stratification of elderly patients is required to weigh the risks of bleeding and ischemia.Before the adventure of further strong evidence related to ischemic benefit of ticagrelor,clopidogrel is still a rational choice for some elderly patients.