From the Guidelines
Ticagrelor is the preferred choice over clopidogrel for patients with acute coronary syndrome (ACS) due to its association with a significant reduction in the primary efficacy endpoint and all-cause mortality, as seen in the PLATO study 1.
Key Considerations
- Ticagrelor has a faster onset of action and is more potent than clopidogrel, but requires twice-daily dosing (typically 90mg twice daily) compared to clopidogrel's once-daily dosing (typically 75mg daily) 1.
- The benefits of ticagrelor are evident irrespective of clopidogrel pretreatment and whether patients have invasive or medical management planned 1.
- However, ticagrelor is associated with a higher rate of non–CABG-related major bleeding and dyspnea compared to clopidogrel 1.
Patient-Specific Factors
- Patients with a history of bleeding or prior stroke/TIA should be approached with caution when considering ticagrelor, as the balance of risks and benefits remains unclear in these populations 1.
- Patients weighing less than the median weight for their sex and those not taking lipid-lowering therapies at randomization may have attenuated benefits from ticagrelor 1.
Guideline Recommendations
- The 2016 ACC/AHA guideline recommends using ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy in patients with ACS treated with DAPT after coronary stent implantation and in patients with NSTE-ACS treated with medical therapy alone 1.
- Prasugrel should not be administered to patients with a prior history of stroke or TIA due to increased risk of intracranial hemorrhage 1.
From the Research
Comparison of Ticagrelor and Clopidogrel
- Ticagrelor is a novel P2Y₁₂ receptor antagonist that has a faster onset of action and provides greater inhibition of platelet aggregation than clopidogrel 2, 3, 4.
- Ticagrelor has been shown to be clinically superior to clopidogrel in patients with acute coronary syndrome, resulting in significantly lower rates of myocardial infarction and vascular death 2, 4.
- The binding of ticagrelor to the P2Y₁₂ receptor is reversible, which allows for a faster offset of effect compared to clopidogrel 2.
- Ticagrelor is indicated to be administered with aspirin, and the clinical benefits of ticagrelor may be less when daily dosages of aspirin exceed 100 mg 2.
Safety and Efficacy
- Bleeding is the most common adverse effect with ticagrelor, although it occurs at rates comparable with those seen for clopidogrel 2, 3, 4.
- Dyspnea is another common adverse effect with ticagrelor, although it is usually not severe and resolves with drug discontinuation 2, 3, 4.
- Ticagrelor has been shown to reduce the risk of stroke, especially ischemic stroke, with significant safety risks 5.
- Ticagrelor is slightly better than clopidogrel and aspirin in preventing stroke, especially ischemic stroke, with significant safety risks 5.
Patient Populations
- Ticagrelor is recommended for prevention of thrombotic events in patients with acute coronary syndromes 6.
- Ticagrelor is preferred over clopidogrel in patients with acute coronary syndromes, especially those with elevated troponin levels or those requiring surgical revascularization 3.
- Ticagrelor may be a potential alternative to aspirin or clopidogrel in some cases, especially for patients with CYP2C19 deficiency 5.