Comparison of Safety and Efficacy Between Clopidogrel and Ticagrelor in Elderly Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

Xiangkai Zhao; Jian Zhang; Jialin Guo; Jinxin Wang; Yuhui Pan; Xue Zhao; Wentao Sang; Kehui Yang; Fengyang Xu; Feng Xu; Yuguo Chen

doi:10.3389/fphar.2021.743259

Comparison of Safety and Efficacy Between Clopidogrel and Ticagrelor in Elderly Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

Front Pharmacol. 2021 Oct 18:12:743259. doi: 10.3389/fphar.2021.743259. eCollection 2021.

Authors

Xiangkai Zhao^{1

2

3

4

5}, Jian Zhang^{1

2

3

4

5}, Jialin Guo^{1

2

3

4

5}, Jinxin Wang^{1

2

3

4

5}, Yuhui Pan^{1

2

3

4

5}, Xue Zhao^{1

2

3

4

5}, Wentao Sang^{1

2

3

4

5}, Kehui Yang^{1

2

3

4

5}, Fengyang Xu^{1

2

3

4

5}, Feng Xu^{1

2

3

4

5}, Yuguo Chen^{1

2

3

4

5}

Affiliations

¹ Department of Emergency Medicine, Qilu Hospital, Shandong University, Jinan, China.
² Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China.
³ Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Shandong University, Jinan, China.
⁴ Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China.
⁵ The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, China.

Abstract

Background: Dual antiplatelet therapy combining aspirin with a P2Y12 adenosine diphosphate receptor inhibitor is a therapeutic mainstay for acute coronary syndrome (ACS). However, the optimal choice of P2Y12 adenosine diphosphate receptor inhibitor in elderly (aged ≥65 years) patients remains controversial. We conducted a meta-analysis to compare the efficacy and safety of ticagrelor and clopidogrel in elderly patients with ACS. Methods: We comprehensively searched in Web of Science, EMBASE, PubMed, and Cochrane databases through 29^th March, 2021 for eligible randomized controlled trials (RCTs) comparing the efficacy and safety of ticagrelor or clopidogrel plus aspirin in elderly patients with ACS. Four studies were included in the final analysis. A fixed effects model or random effects model was applied to analyze risk ratios (RRs) and hazard ratios (HRs) across studies, and I² to assess heterogeneity. Results: A total number of 4429 elderly patients with ACS were included in this analysis, of whom 2170 (49.0%) patients received aspirin plus ticagrelor and 2259 (51.0%) received aspirin plus clopidogrel. The ticagrelor group showed a significant advantage over the clopidogrel group concerning all-cause mortality (HR 0.78, 95% CI 0.63-0.96, I² = 0%; RR 0.79, 95% CI 0.66-0.95, I² = 0%) and cardiovascular death (HR 0.71, 95% CI 0.56-0.91, I² = 0%; RR 0.76, 95% CI 0.62-0.94, I² = 5%) but owned a higher risk of PLATO major or minor bleeding (HR 1.46, 95% CI 1.13-1.89, I² = 0%; RR 1.40, 95% CI 1.11-1.76, I² = 0%). Both the groups showed no significant difference regarding major adverse cardiovascular events (MACEs) (HR 1.06, 95% CI 0.68-1.65, I² = 77%; RR 1.04, 95% CI 0.69-1.58, I² = 77%). Conclusion: For elderly ACS patients, aspirin plus ticagrelor reduces cardiovascular death and all-cause mortality but increases the risk of bleeding. Herein, aspirin plus ticagrelor may extend lifetime for elderly ACS patients compared with aspirin plus clopidogrel. The optimal DAPT for elderly ACS patients may be a valuable direction for future research studies.

Keywords: acute coronary syndrome; clopidogrel; elderly patients; meta-analysis; ticagrelor.