Ticagrelor or clopidogrel in DAPT for acute coronary syndromes: A call for a stepwise approach?
Dual antiplatelet therapy with aspirin combined with ticagrelor or prasugrel is advocated as first-line therapy for patients with acute coronary syndromes (ACS). Both ticagrelor and prasugrel were associated with higher rates of non-coronary artery bypass grafting-related TIMI major bleeding in PLATO and TRITON-TIMI 38, their respective large, international randomised trials versus clopidogrel. However, this risk was offset by a clear decrease in the primary endpoint, a composite of death, myocardial infarction or stroke.
Coinciding with the presentation as a Late Breaking Registry in Barcelona during the Congress of the European Society of Cardiology, EuroIntervention is publishing the results of CHANGE-DAPT from Paolo Zocca et al., a robust registry of ACS patients treated with clopidogrel or ticagrelor over two consecutive periods of time. Differently from PLATO, CHANGE-DAPT included only patients undergoing percutaneous coronary interventions and treated with drug-eluting stents. It therefore represents a meaningful snapshot of current practice, particularly in view of its scrupulous and systematic management, with 99.3% follow-up completed at 12 months.
Surprisingly, the study questions the primacy of ticagrelor as first-line therapy in ACS, due to increased rates of net adverse cerebral or cardiac events, driven by increased bleeding. An accompanying Editorial puts these results into perspective, critically appraising the strengths of the registry but also the limitations that finally discourage the reader from thinking that these contradict the conclusions of PLATO. Even so, the results of CHANGE-DAPT are thought-provoking, in that they corroborate the results of TOPIC, a recent small randomised study suggesting that tailoring antiplatelet therapy with a stepwise approach is a concept worthy of further investigation in large randomised studies.