A comparison of the effects of ticagrelor and clopidogrel in patients with acute ST-segment elevation myocardial infarction: a systematic review and meta-analysis of randomized clinical trials

Abstract

Background: Rupture of unstable coronary atherosclerotic plaque leads to acute ST-segment elevation myocardial infarction (STEMI). Dual anti-platelet therapy is one of the main treatments, and the combination of Aspirin and Clopidogrel is recognized as the standard oral regimen in most cases. Ticagrelor is a new generation of P2Y12 receptor inhibitors. We aimed to compare the effect of Ticagrelor and Clopidogrel in the treatment of patients post-STEMI.

Methods: This study investigated Pub Med, Scopus, Google Scholar Web of Science, and Embase Cochrane Library clinical trials.gov databases. Heterogeneity between studies was assessed using the I2 index and the Q statistic. The random effects model was used to combine studies and the Funnel plot and Egger's test were used to assess the publication bias.

Results: Eleven studies were included in this meta-analysis. 5274 patients in the Ticagrelor and 5,295 patients in the Clopidogrel groups were examined. The mean age of the patients was 58.84 years (2.70) and 59.92 years (3.19) in the Ticagrelor and Clopidogrel groups, respectively. Based on the results of the meta-analysis, compared to Clopidogrel, Ticagrelor had decreased the outcomes of mortality, recurrent myocardial infarction, stroke, and Major Adverse Cardiovascular Events (MACE). However, the post-myocardial infarction bleeding according to Bleeding Academic Research Consortium (BARC) criteria and reperfusion state regarding thrombolysis in myocardial infarction (TIMI) Flow Grading system showed no differences in both groups. However, these effects were not statistically significant.

Conclusions: Ticagrelor decreased the chance of mortality, re-infarction, stroke, and MACE in post-STEMI patients compared to clopidogrel. But there was no difference in the chance of major bleedings (BARC ≥ 3) and improvement in TIMI grade flow between these two drugs. However, none of these findings were statistically significant, and more studies are needed to reach definitive results.

Keywords: Acute coronary syndrome; Anti-platelet; Clopidogrel; Ticagrelor.

Fig. 1

Prisma flow diagram for clinical trials

Fig. 2

Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies

Fig. 3

Risk of bias summery: review authors’ judgments about each risk of bias item for each included study

Fig. 4

The mortality rate in Ticagrelor and Clopidogrel groups

Fig. 5

Stroke rate in Ticagrelor and Clopidogrel groups

Fig. 6

Recurrent myocardial infarction in Ticagrelor and Clopidogrel groups

Fig. 7

Major Adverse Cardiovascular Events in Ticagrelor and Clopidogrel groups

Fig. 8

Overt bleeding in Ticagrelor and Clopidogrel groups

Fig. 9

TIMI flow grade after Ticagrelor and Clopidogrel therapy

Fig. 10

Funnel plots and Egger’s regression test results for each outcome: a BARC, b MACE, c re-MI, d MORTALITY, e STROKE, f TIMI