Ticagrelor vs Clopidogrel for Complex Percutaneous Coronary Intervention in Chronic Coronary Syndrome.

Christian Spaulding, Grégoire Rangé, Laurent Payot, Ota Hlinomaz, Mohammed Nejjari, Mohamad El Kasty, Raphaëlle Dumaine, Cedric Mazeau, Mikael Laredo, Jean-Philippe Collet, Gilles Montalescot, Paul Guedeney, Grégory Ducrocq, Guillaume Cayla, Johanne Silvain, Olivier Morel, Eric Vicaut, Benoit Lattuca, Jean-Jacques Portal, Petr Kala, Olivier Varenne, Zuzana Motovska, Florence Leclercq, Farzin Beygui

Journal: JACC. Cardiovascular interventions 2024;17(3):359-370

PMID: 38355265

Free Full Text on Elsevier Science View on PubMed

Abstract

BACKGROUND

Whether ticagrelor in chronic coronary syndrome patients undergoing complex percutaneous coronary intervention (PCI) can prevent cardiovascular events is unknown.

OBJECTIVES

The authors sought to evaluate outcomes of complex PCI and the efficacy of ticagrelor vs clopidogrel in stable patients randomized in the ALPHEUS (Assessment of Loading with the P2Y inhibitor ticagrelor or clopidogrel to Halt ischemic Events in patients Undergoing elective coronary Stenting) trial.

METHODS

All PCI procedures were blindly reviewed and classified as complex if they had at least 1 of the following criteria: stent length >60 mm, 2-stent bifurcation, left main, bypass graft, chronic total occlusion, use of atherectomy or guiding catheter extensions, multiwire technique, multiple stents. The primary endpoint was a composite of type 4a or b myocardial infarction (MI) and major myocardial injury during the 48 hours after PCI. We compared the event rates according to the presence or not of complex PCI criteria and evaluated the interaction with ticagrelor or clopidogrel.

RESULTS

Among the 1,866 patients randomized, 910 PCI (48.3%) were classified as complex PCI. The primary endpoint was more frequent in complex PCI (45.6% vs 26.6%; P < 0.001) driven by higher rates of type 4 MI and angiographic complications (12.2% vs 4.8 %; P < 0.001 and 19.3% vs 8.6%; P < 0.05, respectively). The composite of death, MI, and stroke at 48 hours (12.7% vs 5.1 %; P < 0.05) and at 30 days (13.4% vs 5.3%; P < 0.05) was more frequent in complex PCI. No interaction was found between PCI complexity and the randomized treatment for the primary endpoint (P = 0.47) nor the secondary endpoints.

CONCLUSIONS

In chronic coronary syndrome, patients undergoing a complex PCI have higher rates of periprocedural and cardiovascular events that are not reduced by ticagrelor as compared with clopidogrel.

Address: Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France; Cardiology Department, Nîmes University Hospital, Montpellier University, ACTION Study Group, Nîmes, France.; Cardiology Department, Nîmes University Hospital, Montpellier University, ACTION Study Group, Nîmes, France.; Cardiology Department, Université de Paris, Hôpital Bichat, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France.; Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France.; Les Grands Prés Cardiac Rehabilitation Centre, Villeneuve St Denis, France.; Département de Cardiologie, Grand Hôpital de l'Est Francilien site Marne-La-Vallée, Marne-la-Vallée, France.; University Hospital Brno, Medical Faculty of Masaryk University Brno, Brno, Czech Republic.; Cardiology Department, Centre Cardiologique du Nord, Paris, France.; Division of Cardiovascular Medicine, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France.; Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France.; Department of Cardiology, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France.; Cardiology Department, General Hospital Yves Le Foll, Saint-Brieuc, France.; Department of Cardiology, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Sudden Cardiac Death Expert Center, INSERM U 971, PARCC, Paris, France.; Cardiology Department, Caen University Hospital, ACTION Study Group, Caen, France.; Cardiology Department, Chartres Hospital, Chartres, France.; Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.; ACTION Study Group, Unité de Recherche Clinique, Hôpital Fernand Widal (AP-HP), EA 4543, Université Paris 1 Panthéon-Sorbonne Paris, Paris, France.; Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France. Electronic address: [email protected].

DOI: 10.1016/j.jcin.2023.12.011