Efficacy and Safety of Ticagrelor in Comparison to Clopidogrel in Elderly Patients With ST‐Segment–Elevation Myocardial Infarctions

BACKGROUND: Current guidelines recommend the new‐generation P2Y12‐inhibitor ticagrelor for patients with acute ST‐segment–elevation myocardial infarctions (STEMIs). The aim of the present study was to assess efficacy and safety of ticagrelor for elderly patients with STEMI (≥75 years) in an all‐comers STEMI registry. METHODS AND RESULTS: Patients with STEMI, aged ≥75 years, treated with primary percutaneous coronary intervention and documented in the Bremen STEMI Registry between 2006 and 2017 entered analysis. The primary efficacy outcome, major adverse cardiac and cerebrovascular events, was defined as a composite of death, myocardial reinfarction, and stroke. The safety outcome was defined as any significant bleeding event within 1 year. To estimate benefit/risk ratio, net adverse clinical events (major adverse cardiac and cerebrovascular events+bleedings) were calculated. Outcomes were estimated in propensity score–matched cohorts to adjust for possible confounders. Of a total of 7466 patients with STEMI, 1087, aged ≥75 years, were selected, of which 552 (51%) received clopidogrel and 535 (49%) received ticagrelor, with similar age (80.9±4.6 versus 80.9±4.6 years) and sex (51% versus 50% female) distributions between treatment arms. The primary efficacy outcome occurred in 32.4% of patients treated with clopidogrel versus 25.5% treated with ticagrelor (P=0.015), with the 1‐year mortality rate at 26.8% versus 21.1% (P=0.035). Because there was no difference in the safety outcome (clopidogrel versus ticagrelor, 4.9% versus 5.1%; not significant), net adverse clinical events were higher for clopidogrel than for ticagrelor: 37.3% versus 30.6% (P=0.028). In a propensity score–matched model, the advantage for ticagrelor on major adverse cardiac and cerebrovascular events remained significant (hazard ratio, 0.69; 95% CI, 0.49‐0.97; P=0.03), whereas 1‐year‐mortality (hazard ratio, 0.89; 95% CI, 0.67–1.27; P=0.5) and 1‐year bleeding events (hazard ratio, 1.1; 95% CI, 0.4–2.3; P=0.8) did not differ. CONCLUSIONS: These results from propensity score–matched registry data show that for elderly patients with STEMI, ticagrelor compared with clopidogrel was associated with a reduction in major adverse cardiac and cerebrovascular events without a significant increase in bleeding events within 1 year.