3353Newer P2Y12 inhibitors in a real-world setting: long-term outcomes from contemporary PCI with newer versus traditional dual antiplatelet regimes

Abstract

Background: Randomised trials have demonstrated reduced major adverse cardiovascular events (MACCE) and stent thrombosis with the use of newer antiplatelet agents following percutaneous coronary intervention (PCI). Current ESC guidelines recommend newer P2Y12 inhibitors (Ticagrelor and Prasugrel) to reduce adverse cardiac events during PCI. However, this raised the caution of many physicians against the inherent bleeding risk associated with these newer agents. Limited data exists from a 'real‐world' unselected PCI population where an 'allcomers' approach is adopted outside the constraints of randomised studies. Methods: All patients undergoing PCI over a two‐year period in a regional interventional unit were analysed. Patients requiring triple therapy with DAPT and anticoagulation were excluded from analysis. The primary end‐point of the study was defined as MACCE (composite of death, MI, stroke, target vessel and lesion revascularization). Secondary end‐points were all‐cause bleeding, TIMI and BARC‐defined bleeding, and stent thrombosis. Patients were classified into three groups; Group A (Aspirin and Clopidogrel, n=462), Group B (Aspirin and Ticagrelor, n=110) and Group C (Aspirin and Prasugrel, n=158). Results: A total of 730 consecutive patients were included in the analysis. The study population median age was 70 years (IQ 60,77) with 69% males. Mean follow up of 12±5 months was achieved in 96.3% of cases. Clinical indication for PCI was either stable angina (47%) or ACS (STEMI 25%; NSTEMI/UA 28%). Univariate analysis suggested a significant reduction of MACCE only in Group B (OR 0.25, 95% CI: 0.08‐0.83, p=0.02) when compared to Group A. When adjusted for age, sex, clinical syndrome and primary PCI status this finding remained statistically significant in multivariate analysis (OR 0.27, 95% CI 0.08‐ 0.90, p=0.03). Kaplan‐Meier log‐rank analysis (see Figure) through to 360‐days demonstrated no statistical difference in DAPT regime on MACCE (long‐rank test, p=0.116). Group A experienced the highest bleeding rates, followed by Groups B and C (see Figure). Multivariate logistic regression identified age>75 years as an independent predictor of bleeding (OR 2.05, 95% CI: 1.22‐3.44, p<0.01). Conclusion: In our observational analysis of an unselected cohort, ticagrelor use was associated with an overall reduction in MACCE. However, there was no significant difference in adverse events between different DAPT regimes at 1 year. Furthermore, our analysis suggests that newer antiplatelet agents (Ticagrelor and Prasugrel) are non‐inferior to Clopidogrel in their risk of bleeding, contrary to the common belief of many physicians. Our study highlights the need for further largescale prospective real‐world analyses to investigate predictors of MACCE and bleeding and identify the groups that are most likely to benefit from newer DAPT regimes, for a tailored approach to patient‐centred care. (Figure Presented).