Ticagrelor vs Clopidogrel for Complex Percutaneous Coronary Intervention in Chronic Coronary Syndrome

Benoit Lattuca; Cedric Mazeau; Guillaume Cayla; Grégory Ducrocq; Paul Guedeney; Mikael Laredo; Raphaëlle Dumaine; Mohamad El Kasty; Petr Kala; Mohammed Nejjari; Ota Hlinomaz; Olivier Morel; Olivier Varenne; Florence Leclercq; Laurent Payot; Christian Spaulding; Farzin Beygui; Grégoire Rangé; Zuzana Motovska; Jean-Jacques Portal; Eric Vicaut; Jean-Philippe Collet; Gilles Montalescot; Johanne Silvain; ALPHEUS Investigators

doi:10.1016/j.jcin.2023.12.011

Ticagrelor vs Clopidogrel for Complex Percutaneous Coronary Intervention in Chronic Coronary Syndrome

JACC Cardiovasc Interv. 2024 Feb 12;17(3):359-370. doi: 10.1016/j.jcin.2023.12.011.

Authors

Benoit Lattuca¹, Cedric Mazeau², Guillaume Cayla¹, Grégory Ducrocq³, Paul Guedeney⁴, Mikael Laredo⁴, Raphaëlle Dumaine⁵, Mohamad El Kasty⁶, Petr Kala⁷, Mohammed Nejjari⁸, Ota Hlinomaz⁷, Olivier Morel⁹, Olivier Varenne¹⁰, Florence Leclercq¹¹, Laurent Payot¹², Christian Spaulding¹³, Farzin Beygui¹⁴, Grégoire Rangé¹⁵, Zuzana Motovska¹⁶, Jean-Jacques Portal¹⁷, Eric Vicaut¹⁷, Jean-Philippe Collet⁴, Gilles Montalescot¹⁸, Johanne Silvain⁴; ALPHEUS Investigators

Affiliations

¹ Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France; Cardiology Department, Nîmes University Hospital, Montpellier University, ACTION Study Group, Nîmes, France.
² Cardiology Department, Nîmes University Hospital, Montpellier University, ACTION Study Group, Nîmes, France.
³ Cardiology Department, Université de Paris, Hôpital Bichat, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France.
⁴ Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France.
⁵ Les Grands Prés Cardiac Rehabilitation Centre, Villeneuve St Denis, France.
⁶ Département de Cardiologie, Grand Hôpital de l'Est Francilien site Marne-La-Vallée, Marne-la-Vallée, France.
⁷ University Hospital Brno, Medical Faculty of Masaryk University Brno, Brno, Czech Republic.
⁸ Cardiology Department, Centre Cardiologique du Nord, Paris, France.
⁹ Division of Cardiovascular Medicine, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France.
¹⁰ Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France.
¹¹ Department of Cardiology, Arnaud de Villeneuve Hospital, Montpellier University, Montpellier, France.
¹² Cardiology Department, General Hospital Yves Le Foll, Saint-Brieuc, France.
¹³ Department of Cardiology, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Sudden Cardiac Death Expert Center, INSERM U 971, PARCC, Paris, France.
¹⁴ Cardiology Department, Caen University Hospital, ACTION Study Group, Caen, France.
¹⁵ Cardiology Department, Chartres Hospital, Chartres, France.
¹⁶ Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.
¹⁷ ACTION Study Group, Unité de Recherche Clinique, Hôpital Fernand Widal (AP-HP), EA 4543, Université Paris 1 Panthéon-Sorbonne Paris, Paris, France.
¹⁸ Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France. Electronic address: gilles.montalescot@aphp.fr.

PMID: 38355265
DOI: 10.1016/j.jcin.2023.12.011

Abstract

Background: Whether ticagrelor in chronic coronary syndrome patients undergoing complex percutaneous coronary intervention (PCI) can prevent cardiovascular events is unknown.

Objectives: The authors sought to evaluate outcomes of complex PCI and the efficacy of ticagrelor vs clopidogrel in stable patients randomized in the ALPHEUS (Assessment of Loading with the P2Y₁₂ inhibitor ticagrelor or clopidogrel to Halt ischemic Events in patients Undergoing elective coronary Stenting) trial.

Methods: All PCI procedures were blindly reviewed and classified as complex if they had at least 1 of the following criteria: stent length >60 mm, 2-stent bifurcation, left main, bypass graft, chronic total occlusion, use of atherectomy or guiding catheter extensions, multiwire technique, multiple stents. The primary endpoint was a composite of type 4a or b myocardial infarction (MI) and major myocardial injury during the 48 hours after PCI. We compared the event rates according to the presence or not of complex PCI criteria and evaluated the interaction with ticagrelor or clopidogrel.

Results: Among the 1,866 patients randomized, 910 PCI (48.3%) were classified as complex PCI. The primary endpoint was more frequent in complex PCI (45.6% vs 26.6%; P < 0.001) driven by higher rates of type 4 MI and angiographic complications (12.2% vs 4.8 %; P < 0.001 and 19.3% vs 8.6%; P < 0.05, respectively). The composite of death, MI, and stroke at 48 hours (12.7% vs 5.1 %; P < 0.05) and at 30 days (13.4% vs 5.3%; P < 0.05) was more frequent in complex PCI. No interaction was found between PCI complexity and the randomized treatment for the primary endpoint (P_interaction = 0.47) nor the secondary endpoints.

Conclusions: In chronic coronary syndrome, patients undergoing a complex PCI have higher rates of periprocedural and cardiovascular events that are not reduced by ticagrelor as compared with clopidogrel.

Keywords: chronic coronary syndrome; complex percutaneous coronary intervention; coronary artery disease; myocardial infarction; ticagrelor.

Publication types

Randomized Controlled Trial

MeSH terms

Acute Coronary Syndrome* / complications
Acute Coronary Syndrome* / diagnostic imaging
Acute Coronary Syndrome* / therapy
Clopidogrel / adverse effects
Clopidogrel / therapeutic use
Humans
Myocardial Infarction* / etiology
Percutaneous Coronary Intervention* / adverse effects
Platelet Aggregation Inhibitors / adverse effects
Platelet Aggregation Inhibitors / therapeutic use
Ticagrelor / adverse effects
Ticagrelor / therapeutic use
Treatment Outcome

Substances

Clopidogrel
Platelet Aggregation Inhibitors
Ticagrelor