Outcomes Among Clopidogrel, Prasugrel, And Ticagrelor In Stemi Patients Undergoing Primary Percutaneous Coronary Intervention From The Total Trial

Abstract Background Robust comparisons between oral P2Y 12 inhibitors (clopidogrel, prasugrel, ticagrelor) in ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) are lacking. We sought to evaluate outcomes based on P2Y 12 inhibitor therapy in patients from the TOTAL trial ( T hr O mbec T omy with PCI versus PCI AL one in patients with STEMI undergoing primary PCI). Methods We grouped 9932 patients by P2Y 12 inhibitor at hospital discharge: clopidogrel (C; n=6500; 65.5%), prasugrel (P; n=1244; 12.5%), or ticagrelor (T; n=2188; 22.0%). The primary composite endpoint of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA Class IV heart failure was examined at one year. Secondary efficacy and safety endpoints were also assessed. Cox proportional hazard ratios were determined and adjusted for confounders via propensity scoring. Results Baseline characteristics differing between the three groups were mainly age ≥75, diabetes, and prior stroke. After adjustment, ticagrelor use was associated with a lower rate of the primary composite outcome compared to both clopidogrel (aHR 0.72; 95% CI=0.57-0.91, p 0.99). Neither prasugrel nor ticagrelor were associated with increased risk of stroke compared to clopidogrel. Ticagrelor was associated with significantly lower major bleeding than clopidogrel. Conclusions In this observational analysis of STEMI patients undergoing PPCI, ticagrelor was associated with improved outcomes compared to clopidogrel and prasugrel. An appropriately powered randomized trial is needed to confirm these findings.