70 Clinical outcomes of clopidogrel versus ticagrelor in the elderly patients with acute coronary syndrome

Background Acute coronary syndrome (ACS) remains one of the leading causes of death in the UK. One of the recent advances in treatment in the treatment of ACS is ticagrelor, a potent P2Y 12 inhibitor, that has become the recommended anti-platelet by the ESC for the treatment of ACS due to its mortality benefit over clopidogrel. The increased anti-platelet inhibition however, also results in significantly increased non-CABG related bleeding. With the ageing population there is a rising proportion of elderly patient (>75) presenting with ACS. The elderly patients generally have greater co-morbidities, higher risk of recurrent ischaemia and also higher risk of bleeding but there is a distinct lack of evidence for this cohort of patients. In the landmark PLATO study for example, only 15% of patients were over the age of 75. It is unclear currently whether ticagrelor is beneficial in these elderly patients. Methods A retrospective cohort study was performed in patients aged 75 and over who were admitted to the Royal Berkshire Hospital (RBH) between 2013 and 2015 with acute coronary syndrome. Patients were discharged either on clopidogrel (147 patients) or ticagrelor (154 patients) according to the local trust protocol at the time. Clinical characteristics and 12 month clinical outcomes (all-cause mortality, cardiovascular deaths, bleeding, angina, STEMI, NSTEMI, dyspnoea and ischaemic stroke) were analysed. Crusade score was used to calculate the bleeding risk. Results The age and baseline clinical characteristics are similar between the two groups. Both had moderate bleeding risk with mean Crusade score of 36.9 for the clopidogrel group and 37 for the ticagrelor group. There was no significant difference in all-cause mortality (8% vs 10%, p=0.55), cardiovascular mortality (2.7% vs 1.9%, p=0.72), ischaemic stroke (0.6% vs 1.9%, p=0.62), admissions with non-cardiac chest pain (5.2% vs 6.1%, p=0.8), angina (6.1% vs 5.2%, p=0.8) or STEMI (2% vs 1.3%, p=0.67) between patients discharged on clopidogrel or ticagrelor. Patients on clopidogrel however had significant increased re-admissions with NSTEMI compared to ticagrelor (7.5% vs 1.9%, p=0.028). No increase in either major (8.4 vs 8.1%, p=1) or minor bleeding (20% vs 17%, p=1) was observed in the ticagrelor compared to the clopidogrel group using TIMI-bleeding criteria. Only 1 patient reported significant dyspnoea in the ticagrelor group. Conclusions Elderly patients discharged on ticagrelor had reduced re-admissions with NSTEMI without an increase in either major or minor bleeding compared to patients discharged on clopidogrel.