Authors' objectives: Background To prevent further cardiovascular (CV) events after acute coronary syndrome (ACS), including myocardial infarction (MI) with or without ST-segment elevation as well as unstable angina pectoris, dual antiplatelet therapy (DAPT) is usually prescribed for 12 months, mainly ticagrelor or clopidogrel, each combined with acetylsalicylic acid (ASA). Based on a large doubleblind randomised controlled trial (RCT, acronym: PLATO), published in 2009 and showing that ticagrelor was superior to clopidogrel regarding the primary composite endpoint of vascular death, non-fatal myocardial infarction (MI) and stroke without inducing an increased risk of major bleeding, the European Society of Cardiology recommends ticagrelor and ASA as the first-line DAPT treatment. In 2019, more than 80% of the 2,758 ACS patients in Region Västra Götaland were treated with ticagrelor, the remaining 20% primarily being patients treated with clopidogrel because of concomitant treatment with a direct-acting oral anticoagulant or warfarin. However, improvements in revascularisation techniques make it uncertain to what extent the PLATO results are applicable in current clinical practice. For instance, percutaneous coronary intervention (PCI) techniques have improved, with a reduced risk of thrombotic events. Further, the increased age in the population at issue for DAPT may affect the risk of adverse events as the risk of bleeding increases by age. Question at issue: In ACS patients subjected to DAPT, including those of older age, is clopidogrel combined with ASA similar to ticagrelor combined with ASA, regarding the outcomes mortality, MI, bleeding, stent thrombosis, angina, rehospitalisation, health-related quality of life (HRQL), and dyspnea?

Authors' results and conclusions: This HTA shows that clopidogrel, in ACS patients overall, is probably slightly less efficient compared with ticagrelor in reducing the risk of MI and stent thrombosis. For all-cause and CV mortality, clopidogrel may be slightly less efficient or show little or no difference. Regarding adverse effects, use of clopidogrel is favourable, with a reduced risk of clinically significant bleeding and dyspnea. For major bleeding, there may be little or no difference between these DAPT alternatives, or clopidogrel may result in a reduced risk. In older ACS patients, available evidence suggests little or no difference between clopidogrel and ticagrelor regarding all-cause/CV mortality and MI, but the risk of clinically significant bleeding is probably substantially lower with clopidogrel and the risk of major bleeding is probably also lower.

Project Status: Completed

URL for project: https://mellanarkiv-offentlig.vgregion.se/alfresco/s/archive/stream/public/v1/source/available/sofia/su4372-1728378332-393/native/2021_123%20HTA-rapport%20ticagrelor.pdf

Year Published: 2021

URL for published report: https://mellanarkiv-offentlig.vgregion.se/alfresco/s/archive/stream/public/v1/source/available/sofia/su4372-1728378332-393/native/2021_123%20HTA-rapport%20ticagrelor.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Organisation Name: The Regional Health Technology Assessment Centre

Contact Address: The Regional Health Technology Assessment Centre, Region Vastra Gotaland, HTA-centrum, Roda Straket 8, Sahlgrenska Universitetssjukhuset, 413 45 GOTHENBORG, Sweden

Contact Name: hta-centrum@vgregion.se

Contact Email: hta-centrum@vgregion.se