Safety and Efficacy of Ticagrelor vs Clopidogrel in Patients With Acute Coronary Syndrome

Study Overview
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Brief Summary
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Multicenter post-approval observational retrospective cohort study in routine clinical practice (Real World Evidence Study) to assess the 1-year safety profile associated with ticagrelor and clopidogrel therapy in a contemporary reprospective cohort of patients who survived the initial 30-day period after the index hospitalization for acute coronary syndrome (ACS).

Detailed Description
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To date, there are still a paucity of data on the medium- and long-term safety and efficacy outcomes of new antiplatelet agents, namely Ticagrelor and Prasugrel, compared to Clopidogrel in a real-world ACS setting. The ARIAM-Andalusia multicentre Registry, and the CREA-ARIAM multicentre Registry (ClinicalTrials.gov Identifier: NCT02500290; Fundación Pública Andaluza Progreso y SaludIdentifier: FPS-AAS-2014-01), are two Real World Evidence (RWE) studies aimed to investigate real-world practice on antiplatelet treatment in patients with ACS in Andalusia (Western Spain). Our group are interested in performing a retrospective observational pilot analysis using data from patients with ACS admitted to cardiovascular intensive care units in Andalusia (Spain), who were prospectively included in the ARIAM-Andalusia multicentre Registry, and the CREA-ARIAM multicentre Registry (ClinicalTrials.gov Identifier: NCT02500290; Fundación Pública Andaluza Progreso y Salud-Identifier: FPS-AAS-2014-01) between 2014 and March 2019. The main findings from the RWE study revealed a consistent net clinical benefit of Ticagrelor vs Clopidogrel resulted in a significant reduction of short-term all-cause mortality favored Ticagrelor. In this scenario, after baseline imbalance adjustment using propensity score matching (PSM) and IPTW (inverse probability of treatment weight) methods, the net clinical benefit with Ticagrelor persisted. Preliminary results of the above mentioned study have been presented as an oral communication at the Annual Scientific Meeting of the Spanish Society of Cardiology (Madrid, October 2017). The aim of this new pilot study suggested is to describe the efficacy and safety of Ticagrelor vs Clopidogrel after the first 30 days from hospital discharge and up to 1 year follow-up.

Official Title
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ANTIPLATELET TREATMENT IN ACUTE CORONARY SYNDROMES. SAFETY AND EFFICACY OF ANTIPLATELET SWITCHING Safety and Efficacy of Ticagrelor vs Clopidogrel in Patients With Acute Coronary Syndrome

Conditions
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Acute Coronary Syndromes

Intervention / Treatment
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* Drug: Clopidogrel
* Drug: Ticagrelor


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All-comers ACS population (with or without ST segment elevation, including unstable angina) with: A recent CCU admission (patients included in the ARIAM-CREA study within 1 week from the index ACS admission between March 1, 2015 to March 31, 2018), irrespective of either the initial management (invasive or non-invasive) or the revascularization procedure (PCI with stenting or CABG) discharged on DAPT including either Ticagrelor or Clopidogrel and have survived the first 30-day follow-up period from the index ACS event and could complete a 12-month follow-up. Exclusion Criteria: Age < 18 years. Subjects who died in the first 30-day follow-up period from the index ACS event, including those who died during the index admission. A medical condition likely to limit survival to less than 1 year. Any factors judged by the local investigators to be likely to limit adherence to pharmacological treatment. Failure to obtain informed consent from participant. Currently enrolled in an interventional clinical research trial involving an investigational product (drug) or device Not available for follow-up over a minimum of 365 days, e.g. no fixed home address. Pregnancy, breast-feeding, or intend to become pregnant during the study period population should be always considered as exclusion criterion. Non-ACS diagnosis at discharge, i.e., acute myocarditis, Takotsubo syndrome, pulmonary thromboembolism or acute aortic syndromes. Myocardial infarction secondary to an ischaemic imbalance or type 2 myocardial infarction (Third Universal Definition of MI), in instances of myocardial injury with necrosis, where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand, i.e., anaemia, sepsis, tachyarrhythmias, hypotension, heart failure… Patients not discharged on dual antiplatelet therapy (DAPT) consistent on low dose of ASA plus a P2Y12platelet receptor inhibitor (Clopidogrel or Ticagrelor) Patient discharged on DAPT including Prasugrel as the P2Y12 inhibitor drug. Hypersensitivity to ticagrelor or any of the excipients. Active pathological bleeding. History of intracranial haemorrhage (ICH). Severe hepatic impairment.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Clopidogrel<br>Clopidogrel is a prodrug that requires metabolic activation in two stepsby hepatic CYP450 enzymes to produce the active metabolite that inhibits platelet aggregation. The active metabolite of clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet P2Y12 receptor and the subsequent ADP-mediated activation of the glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. Consequently, due to the irreversible binding to the P2Y12 receptor,platelets exposed to clopidogrel's active metabolite are affected for the remainder of their lifespan (about 7 to 10 days) and recovery of normal platelet function occurs at a rate consistent with the normal platelet turnover. Clopidogrel was approved by the European Commission on 15 July 1998 for the secondary prevention of atherothrombotic events in adult patients with ACS. | Drug: Clopidogrel<br>* Describe the safety of Ticagrelor vs Clopidogrel use, in patients with ACS in terms of major bleeding between 30 days and one year after the index ACS event. An ITT approach and IPCW method to adjust for change of initial treatment will be used for the analysis.<br>|
| Ticagrelor<br>Ticagrelor is a nucleoside analogue member of the chemical class cyclopentyltriazolopyrimidines (CPTP), which is a selective and reversible ADP- receptor antagonist acting on the platelet P2Y12 receptor. This prevents the binding of ADP to the receptor which attenuates plateletactivation and aggregation.The drug was approved by the European Commission on December 3, 2010, for the prevention of thrombotic events (cardiovascular death, myocardial infarction and stroke) in patients with ACS (unstable angina, non ST elevation Myocardial Infarction [NSTEMI] or ST elevation Myocardial Infarction [STEMI]) including patients managed medically, and those who are managed with percutaneous coronary intervention (PCI) or coronary artery by-pass grafting (CABG). | Drug: Ticagrelor<br>* Describe the safety of Ticagrelor vs Clopidogrel use, in patients with ACS in terms of major bleeding between 30 days and one year after the index ACS event. An ITT approach and IPCW method to adjust for change of initial treatment will be used for the analysis.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Major bleeding | Defined as BARC type≥ 3 according to the Bleeding Academic Research Consortium (BARC) definition at 1-year follow-up after the index ACS. | During 2 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Thrombolysis in Myocardial Infarction (TIMI) | Bleeding criteria | During 2 months | 
| BARC definition | Bleeding criteria | During 2 months | 
| Major Adverse Cardiac and Cerebrovascular Events (MACCE) | Defined as the composite of all-cause mortality, myocardial infarction (MI), target lesion revascularization (TLR), stent thrombosis and stroke or TIA at 1-year follow-up after the index ACS admission. | During 2 months | 
| All-cause mortality | Component of MACCE | During 2 months | 
| Myocardial infarction | Component of MACCE | During 2 months | 
| Target lesion revascularization | Component of MACCE | During 2 months | 
| Stent thrombosis | Component of MACCE | During 2 months | 
| Stroke | Component of MACCE | During 2 months | 
| Net clinical benefit/Net Adverse Clinical Event (NACE): | Defined as the composite of the efficacy (Major Adverse Cardiac and Cerebrovascular Events-MACCE) and safety (BARC type≥ 2 bleeding episodes according to the Bleeding Academic Research Consortium (BARC) definition for bleeding) outcomes at 1 year after the index ACS. | During 2 months |