January 26, 2023

Dr Warwick Jaffe joins Dr Patricia Ding to discuss Ticagrelor vs Clopidogrel in Patients with Acute Coronary Syndrome.

Morning work morning patricia right okay so today we’re going to talk about clopidogrel and ticagrelor now firstly uh well can you tell us about the difference between clopidogrel and tychargulo well ticagrelor is a more potent p212y inhibitor patricia and it’s mainly used in people after acute coronary syndrome so most gps don’t actually prescribe it it does

Require a chem number and it is a restricted drug what are the side effects of ticagrelor well the main side effects of tai kagura are excessive bleeding because it’s more potent than clopidogrel is often a lot more bleeding and secondly and about 20 of patients they get this unusual breathlessness with it it’s sort of like an asthma type thing and it can be

Quite disabling right so at the moment we use ticagrelor as the standard treatment after acute coronary syndrome and clopidogrel often is used in stable angina elective pcis and in some dhbs clopidogrel is used in elderly population after acute coronary syndrome now there’s a new trial called talus ami trial which is a trial comparing aspirin with ticagrelor

Versus de-escalation from tychargular to clopidogrel can you tell us about that one yeah well i guess the rationale behind this trial is that a lot of people have a heart attack get put on this very powerful drug tacagra law and yes it improves their outlook at 12 months but it’s at the expense of bleeding and so the main risk after a heart attack is blocking

Your stent or having another event that occurs within about the first 30 days so what people have been thinking is could they put people on the strong anticoagulant that’s tarkage law for the first 30 days and then perhaps use a weaker one such as clopidogrel for for the remainder of that 12-month period that’s the rationale behind the trial okay so basically

We thought ticagrelo was slightly more superior than clopidogrel based on the plato trial published in 2009 however this is at this expense of increased bleeding risk because that trial only looked at cardiac events now this one i believe as a open label multi-center trial and can you tell us about the um the design of the trial and the end points please yeah

There’s just a little bit more than two and a half thousand patients in this trial and they all had acute coronary syndrome so either a stemi or a non-stemi and they all got given the usual treatment which is aspirin and to kagaro 90 milligrams twice daily at a month half of the patients were then randomized to receive and aspen and the other half just stayed on

The usual treatment of ticagrelor and aspirin and then they we they were then followed for a year’s uh time yeah and these are stemi and non-stemi patients right yeah yeah and the end point of of course was how many heart attacks strokes people had how many people were alive but the second and most important end point was how much bleeding the patients had and

How much morbidity there was from bleeding right so tell us about the results okay so the results were that in the group that was given clopidogrel and aspirin they actually did a little bit better because they had less bleeding but there was no difference in the rate of strokes or heart attacks or deaths so in fact it was equivalent to to kagura in preventing

Those terrible things but better than to kagura because there was less bleeding so in other words this trial helps us to find the fine balance point between the benefit of dual entry platelet therapy and minimizing the bleeding risk yes it does but of course it’s just one trial and we have to be careful the child hasn’t been fully published yet secondly with

These trials you always have to look at what patients who are included and often the sickest and worst patients aren’t put into trials just that’s just the way the world works and so this trial didn’t have that many people with uh severe triple vessel coronary disease and it didn’t have so many people with left main stem stenosis and at the moment i don’t think

Any of the public hospitals in auckland have changed hocus pocus to giving everyone takeaway for a month then changing to clipital but what it does tell the general practitioner is if you have someone that comes out of hospital who’s on all these drugs etc and they’re you think that they’re getting side effects from thai cagura it would be very reasonable to

Discuss this with the doctor registrar or specialist at the hospital and say look i really would like to change this person to clopidogrel and i think we’ll have a pretty low threshold uh for doing this now and especially if they can’t take um to calculate because they’ve got um significant breathing difficulties right i think that cleopatra is going to be a

Very good option for those patients and for those who are obviously bleeding it’s okay to change over without a loading dose of clothing yep that’s exactly right for those people that have serious bleeding that’s a big problem and um you know generally we’re realizing now that a lot of the bleeding in these patients is actually due to the aspirin what’s what

When they when they’re on the combination there has been a tendency to stop aspin and just keep the person going on either clopidogrel or tychargal or as monotherapy and there are certainly some studies looking at monotherapy in patients who’ve had bleeding problems after heart attacks and they look pretty favorable right okay that’s very useful i’ve learned

Something new as well thank you warrick no problem you’re welcome patricia you

Transcribed from video
Ticagrelor vs Clopidogrel in Patients with Acute Coronary Syndrome By Ascot Cardiology Group Auckland