What are the advantages of Brilinta (ticagrelor) over Plavix (clopidogrel) in patients undergoing Percutaneous Coronary Intervention (PCI)?

Advantages of Ticagrelor (Brilinta) Over Clopidogrel (Plavix) After PCI

Ticagrelor provides more potent and rapid platelet inhibition compared to clopidogrel in patients undergoing PCI, resulting in reduced rates of major adverse cardiovascular events, including death from vascular causes, myocardial infarction, and stroke. 1

Key Advantages of Ticagrelor

• Ticagrelor demonstrates superior reduction in composite endpoints of death from vascular causes, myocardial infarction, and stroke compared to clopidogrel in patients undergoing PCI 1

• Ticagrelor provides more rapid onset of action and more consistent platelet inhibition than clopidogrel, which is particularly beneficial in high-risk PCI scenarios 2

• Ticagrelor is associated with lower rates of stent thrombosis compared to clopidogrel, a critical advantage for maintaining stent patency after PCI 1

• In patients with atrial fibrillation on oral anticoagulation who underwent PCI for myocardial infarction, ticagrelor was associated with reduced ischemic risk without increased bleeding compared to clopidogrel 3

• Ticagrelor achieves significantly lower platelet reactivity units (PRU) at both 4 and 24 hours post-PCI compared to clopidogrel, indicating more effective platelet inhibition 2

Clinical Evidence Supporting Ticagrelor

The PLATO trial demonstrated that ticagrelor, compared with clopidogrel, reduced the rate of the composite endpoint of death from vascular causes, myocardial infarction, or stroke in patients undergoing PCI 1. This advantage was maintained across various patient subgroups and clinical scenarios.

In patients who have experienced cardiac arrest and are undergoing therapeutic hypothermia after PCI, ticagrelor provides more effective platelet inhibition than clopidogrel, which is particularly important as clopidogrel shows diminished efficacy in this setting 4.

For patients receiving fibrinolytic therapy for STEMI who subsequently undergo early PCI, ticagrelor provides more prompt and potent platelet inhibition compared to clopidogrel. In one study, 87.8% of ticagrelor-treated patients achieved adequate platelet inhibition (PRU ≤208) at 4 hours post-PCI compared to only 57.6% of clopidogrel-treated patients 2.

Considerations for Specific Patient Populations

• For patients with acute coronary syndromes (ACS) undergoing PCI, ticagrelor is recommended in preference to clopidogrel due to superior reduction in ischemic events 1

• In patients with atrial fibrillation requiring oral anticoagulation who undergo PCI, clopidogrel is generally preferred over ticagrelor due to lower bleeding risk when triple therapy is required 1

• For patients with chronic coronary syndromes (CCS) undergoing elective PCI, clopidogrel remains the standard P2Y12 inhibitor of choice, as ticagrelor has not demonstrated significant advantages in this specific population 1, 5

Bleeding Risk Considerations

While ticagrelor provides superior platelet inhibition, it is associated with increased non-CABG-related bleeding compared to clopidogrel 1. This risk must be balanced against the ischemic benefits:

• In high-risk patients who underwent PCI and completed 3 months of dual antiplatelet therapy (DAPT), switching to ticagrelor monotherapy (without aspirin) was associated with lower bleeding rates than continued DAPT, while maintaining similar protection against ischemic events 6

• Ticagrelor should be used with caution in older patients and those with higher bleeding risk 1

Dosing Considerations

• Ticagrelor: Loading dose of 180 mg orally, followed by maintenance dose of 90 mg orally twice daily 1
• Clopidogrel: Loading dose of 600 mg orally, followed by maintenance dose of 75 mg orally daily 1

Practical Algorithm for P2Y12 Inhibitor Selection After PCI

1. For ACS patients (STEMI, NSTEMI) undergoing PCI:

   • First choice: Ticagrelor (unless contraindicated) 1
   • Alternative if bleeding risk is high: Clopidogrel 1

2. For patients with chronic coronary syndromes undergoing elective PCI:

   • Standard choice: Clopidogrel 1, 5
   • Consider ticagrelor only in selected high-risk patients with complex PCI and low bleeding risk 1

3. For patients requiring triple therapy (PCI plus atrial fibrillation):

   • Preferred P2Y12 inhibitor: Clopidogrel (due to lower bleeding risk) 1

4. For post-fibrinolytic PCI in STEMI:

   • Consider switching from clopidogrel to ticagrelor for more effective platelet inhibition 2

Caveats and Pitfalls

• Ticagrelor requires twice-daily dosing, which may affect medication adherence compared to once-daily clopidogrel 1

• Ticagrelor can cause dyspnea in some patients, which may be misinterpreted as heart failure or pulmonary issues 1

• Ticagrelor should not be discontinued abruptly due to potential rebound platelet activation and thrombotic events 1

• When transitioning between P2Y12 inhibitors, appropriate loading doses must be considered to maintain adequate platelet inhibition 1