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Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in East-Asian Patients with Acute Coronary Syndrome: Large Cohort Study

  • Original Research Article
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Abstract

Aim

A high risk of bleeding is observed in East Asian patients with acute coronary syndrome (ACS). Therefore, the choice between two antiplatelet therapy drugs, ticagrelor and clopidogrel, remains controversial in this population with ACS. This study aimed to use a large cohort database to assess the clinical outcomes of ticagrelor and clopidogrel therapy, including major bleeding, recurrent ACS, and mortality, in this population.

Methods

Between January 2009 and December 2019, 43,696 patients were diagnosed with ACS based on the medical history (International Classification of Diseases [ICD] code) of the Chang Gung Research Database. After excluding patients without percutaneous coronary intervention, with concurrent medical problems, and on non-standard dual antiplatelet therapy (DAPT) or a single antiplatelet agent, 18,046 patients were recruited for analysis. Ticagrelor- and clopidogrel-based DAPT were administered to 3666 patients and 14,380 patients, respectively. Baseline characteristics and clinical outcomes were compared between the two groups. A total of 4225 patients were defined as a high-bleeding-risk subgroup according to Academic Research Consortium for High Bleeding Risk (ARC-HBR) score (met one major or two minor criteria), of which 466 and 3759 patients received ticagrelor- and clopidogrel-based DAPT, respectively.

Results

Before propensity score matching (PSM), younger age, higher prevalence of male sex, and higher body mass index were noted in the ticagrelor-based DAPT group in the whole cohort and high-bleeding-risk subgroup. After PSM, no difference in baseline characteristics and comorbidities between ticagrelor-based and clopidogrel-based DAPT groups in the whole cohort and high-bleeding-risk subgroup was noted. The Kaplan–Meier curves of recurrent ACS and major bleeding were significantly lower in the ticagrelor-based DAPT group than in the clopidogrel-based DAPT group, and that of cardiovascular (CV) and all-cause mortality showed no significant differences. After PSM, in the high-bleeding-risk subgroup, the Kaplan–Meier curve of recurrent ACS was significantly lower in the ticagrelor-based DAPT group than in the clopidogrel-based DAPT group, and that of major bleeding, CV, and all-cause mortality showed no significant differences.

Conclusion

In this large cohort study, patients receiving ticagrelor-based DAPT were at lower risk of recurrent ACS compared to those receiving clopidogrel-based DAPT, especially in the patients with myocardial infarction. Ticagrelor-based DAPT did not result in a higher risk of major bleeding in the whole ACS population and high-bleeding-risk subgroup. The rate of CV and all-cause mortality were similar between both the groups.

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Acknowledgements

The authors thank Yun-Yu Hsieh for the statistical assistance and acknowledge the support of the Biostatistics Center of Kaohsiung Chang Gung Memorial Hospital (Grant CORPG8L0471) in study design, data monitoring, data analysis, and data interpretation.

Author information

Author notes

  1. Chih-Yuan Fang equal contribution as Wei-Chieh Lee as first author and Hsiu-Yu Fang contribution as corresponding author.

Authors and Affiliations

  1. Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Wei-Chieh Lee

  2. Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan

    Wei-Chieh Lee

  3. Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan

    Wei-Chieh Lee, Chih-Yuan Fang, Tien-Yu Chen, Yen-Nan Fang, Huang-Chung Chen, Po-Jui Wu & Hsiu-Yu Fang

  4. School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan

    Wei-Chieh Lee

  5. Biostatistics Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    Yi-Hsuan Tsai & Yun-Yu Hsieh

  6. Division of Cardiology, Department of Internal Medicine, Jen-Ai Hospital, Taichung, Taiwan

    Hsiu-Yu Fang

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Corresponding author

Correspondence to Wei-Chieh Lee.

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Funding

This study was supported by the research program of Kaohsiung Chang Gung Memorial Hospital (Grant CORPG8L0471).

Conflict of interest

Wei-Chieh Lee, Chih-Yuan Fang, Yi-Hsuan Tsai, Yun-Yu Hsieh, Tien-Yu Chen, Yen-Nan Fang, Huang-Chung Chen, Po-Jui Wu, and Hsiu-Yu Fang declare that they have no potential conflicts of interest that might be relevant to the contents of this article.

Ethics approval

The study complied with the Declaration of Helsinki and was approved by the ethics committee of Kaohsiung Chang Gung Memorial Hospital (number: 202101010B0C501).

Consent to participate

Written informed consent was waived by the institutional review board (IRB) due to the retrospective study.

Consent for publication

Written informed consent was waived by the IRB due to the retrospective study.

Availability of data and material

The study data are available from the corresponding authors upon request. This study was based, in part, on data from the Chang Gung Research Database provided by the Chang Gung Memorial Hospital. The interpretation and conclusions contained herein do not represent the positions of the Chang Gung Memorial Hospital.

Code availability

Not applicable.

Author contributions

WCL designed the study and drafted the manuscript. WCL and CYF established the rationale for the study. WCL, YHT, and YYH performed comprehensive analyses. TYC, YNF, HCC, and PJW prepared figures. HYF drafted the final manuscript. All authors have reviewed the manuscript.

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Lee, WC., Fang, CY., Tsai, YH. et al. Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in East-Asian Patients with Acute Coronary Syndrome: Large Cohort Study. Am J Cardiovasc Drugs 23, 573–581 (2023). https://doi.org/10.1007/s40256-023-00603-7

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