Ticagrelor is safe in ST-elevation myocardial infarction patients who received fibrinolysis
TREAT study filled in the gap. In STEMI patients aged < 75 years who received fibrinolysis, ticagrelor was non inferior to clopidogrel for major bleeding at 30 days. The rates of fatal bleeding and intracranial bleeding were similar. 89.4% patients in TREAT study received clopidogrel prior to randomization. Both groups were randomized with a median of 2.6 hours from chest pain to fibrinolytic therapy and 11.4 hours after fibrinolytic therapy to randomization.
At 1 year, the major bleeding, fatal bleeding and intracranial bleeding were similar. The exploratory efficacy outcomes including composite outcome of death from vascular causes, myocardial infarction or stroke was not statistically different between two groups. However, it showed the trend favoring ticagrelor which is similar to PLATO study (4). There were a couple of things to keep in mind. TREAT study was powered for safety endpoint, not efficacy endpoint. Because of the trial design, the STEMI patients who survived, did not have reocclusion, hemodynamic instability or bleeding at 12 hour-randomization-gap likely represented low risk STEMI patients. The trial size has be much bigger to demonstrate ischemic superiority when the ischemic event is low; therefore, the possibility of such study to be conducted is low.
Although there is still some evidence gap, there is no reason to withhold ticagrelor in ST-elevation patients who received fibrinolysis when the safety has been proven.