Efficacy And Safety Of Ticagrelor Versus Clopidogrel In Patients With Acute Coronary Syndrome Undergoing Complex Percutaneous Coronary Intervention

Objectives To assess the long-term prognosis of patients who underwent complex percutaneous coronary intervention(PCI)in real world,and compared the efficacy and safety of ticagrelor versus clopidogrel in patients undergoing complex PCI.Methods This study was a single-center,real-world retrospective study.Acute coronary syndrome(ACS)patients with at least one stent implanted in the General Hospital of Northern Theater Command from March 2016 to March 2019 were enrolled in this study.All of subjects were treated with dual antiplatelet therapy(DAPT)for at least 12 months after hospitalization.Enrolled participants were initially divided into the complex PCI group and the non-complex PCI group according to whether undergoing PCI procedures on complex lesion or nor and compared the long-term prognosis between the two groups.We defined the complex lesion as bifurcation lesions,ostial lesions,chronic total occlusion(CTO),tortuous vessels,calcified lesions,diffused lesions,thrombotic lesions and restenosis in this study.Subsequently,patients in the complex-PCI group were stratified into ticagrelor group and clopidogrel group according to the different types of P2Y12 inhibitors(ticagrelor or clopidogrel)and comparing the efficacy and safety of DAPT composed of aspirin plus either ticagrelor or clopidogrel in patients undergoing complex PCI.The primary endpoint in our study was a composite of cardiac death,myocardial infarction(MI)and ischemic stroke.The secondary endpoints were all-cause death,MI,ischemic stroke,the Bleeding Academic Research Consortium(BARC)type 2,3,5 and type 3,5 bleeding at 12 months.In order to minimize the impact of confound factors(baseline and procedural characteristics)on clinical outcomes,propensity score matching(PSM)was conducted as a 1:1 ratio in ticagrelor group and clopidogrel group using the nearest neighbor matching.Results A total of 20095 patients were enrolled in this study,of whom 62.3%(N = 12512)underwent complex PCI and 37.7%(N = 7583)underwent non-complex PCI.There were significant differences in baseline data between the two groups.Compared with the non-complex PCI group,patients who underwent complex PCI were more likely to be male,had a higher proportion of anemia,previous history of stroke,PCI or coronary artery bypass grafting(CABG)(P < 0.05).Patients with complex PCI also had a lower left ventricular ejection fraction(LVEF)and estimated glomerular filtration rate(P < 0.05).Additionally,patients in complex PCI group were implanted with more stents,with a longer average stent length and a higher average Synergy between PCI with Taxus and Cardiac Surgery(SYNTAX)score(P < 0.05).Among patients with complex PCI,8065(64.8%)patients administrated clopidogrel as a composite of DAPT,and 4373(35.2%)used ticagrelor after hospitalization(74 individuals were excluded due to missing data on medication at discharge).Among the complex PCI group,patients received ticagrelor were younger,and more likely to be male,had a lower percentage of anemia,a higher e GFR and lower LVEF than patients received clopidogrel.The clopidogrel group had more comorbidities including hypertension and peripheral vascular disease,more previous history of stroke and CABG.The ticagrelor group was also found to have more bifurcation lesions,CTO,thrombotic lesions and diffused lesions,and to be implanted with more stents with a higher SYNTAX score in comparison with the clopidogrel group.After PSM with a total of 3210 matched pairs,baseline and procedure characteristics were comparable between two groups.Compared with patients undergoing non-complex PCI,patients who received complex PCI had a significantly higher risk of primary endpoint at 12 months(2.82% vs.1.49%,P < 0.01).Rates of cardiac death(1.69% vs.0.54%,P < 0.01)and MI(0.68% vs.0.34%,P < 0.01)were also significantly higher in the complex PCI group than those in the non-complex PCI group,except for ischemic stroke(0.58% vs.0.66%,P = 0.50).Among patients who underwent complex PCI,patients received ticagrelor experienced a significantly fewer primary endpoint events compared with patients treated with clopidogrel at 12 months(1.74% vs.2.84%,P < 0.01).And this statistical significance was mainly driven by the significantly lower risks of cardiac death(0.98% vs.1.50%,P = 0.02)and ischemic stroke(0.25% vs.0.76%,P < 0.01)in ticagrelor group.Additionally,incidences of BARC 2,3,5(4.05% vs.3.53%,P = 0.15)and BARC 3,5 bleeding events(2.38% vs.2.01%,P = 0.17)were comparable between two groups.Results after PSM was consistent with the main outcomes.Conclusions Patients with ACS undergoing complex PCI experienced a significantly higher risk of ischemic events than patients with non-complex PCI at 12 months.Moreover,the incidences of major bleeding were comparable between the two groups.For ACS patients who underwent complex PCI,the aspirin combined with ticagrelor treatment was associated with a significantly reduced risk of ischemic events than clopidogrel treatment without increasing the occurrence of major bleeding.