Ticagrelor versus Clopidogrel in Patients with Severe Renal Insufficiency Undergoing PCI for Acute Coronary Syndrome

Abstract

Background: Current guidelines recommend the use of potent antiplatelet agents in patients undergoing percutaneous coronary intervention (PCI) following an acute coronary syndrome (ACS). However, data about optimal platelet inhibition in severe renal insufficiency patients are scarce. The purpose of this study is to determine if ticagrelor is more effective than clopidogrel in patients with ACS and severe renal insufficiency treated with PCI.

Methods: We retrospectively enrolled patients with ACS and severe renal insufficiency (eGFR ≤ 30 ml/min·1.73 m² or dialysis) who underwent PCI at our hospital between January 2015 and March 2020. We used the adjusted Cox proportional hazards models to analyze the 1-year outcome endpoints, including the primary endpoint (the composite of cardiovascular death, recurrence of MI, or nonfatal ischemic stroke), death from any cause, and bleeding events (Bleeding Academic Research Consortium, BARC criteria).

Results: A total of 276 patients with ACS and severe renal insufficiency who were treated with PCI with ticagrelor (n = 108) or clopidogrel (n = 168) were included in the study. After adjustment, there was no statistical difference in risk of the primary endpoint (HR, 0.78; 95% CI, 0.46-1.33; P=0.367) and death from any cause (HR, 0.86; 95% CI, 0.38-1.89; P=0.708) in the ticagrelor group against the clopidogrel group. However, the risk of total bleeding was significantly higher in the ticagrelor group (HR, 3.01; 95% CI, 1.81-5.62; P=0.01). Subgroup analysis according to the confounders did not identify any significant subgroup heterogeneity.

Conclusion: Ticagrelor did not improve the major adverse cardiovascular events and all-cause mortality when compared to clopidogrel, but significantly increased the risk of bleeding in Chinese patients with ACS and severe renal insufficiency undergoing PCI.

Figure 1

Flowchart of patient selection.

Figure 2

Kaplan–Meier curve for the 1-year primary endpoint (a) and total BARC bleeding (b) between clopidogrel and ticagrelor group.

Figure 3

Forest plot illustrating the adjusted HR for primary outcomes (a) and total BARC bleeding (b) stratified on confounding factors (including gender, ACS staging, hemodialysis, use of glycoprotein IIb/IIIa inhibitors, and low-molecular heparin). STEMI, ST-elevation myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; LMWH, low-molecular-weight heparin.