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Ticagrelor is safe in ST-elevation myocardial infarction patients who received fibrinolysis

Narathip Chunhamaneewat, MD
Faculty of Medicine Siriraj Hospital, Mahidol University
22 Apr 2019
Compared with clopidogrel, ticagrelor reduced the rate of vascular death, myocardial infarction or stroke without an increase in bleeding in the patients with acute coronary syndrome (1).  However, ST-elevation myocardial infarction (STEMI) patients who had received fibrinolytic therapy were not included in the study.  There was no pharmacological reason to consider potent P2Y12 inhibitors would not be beneficial in this subgroup, but the concern was bleeding risk which might have been added after fibrinolysis.  Despite a gap of evidence, European guidelines recommended an arbitrary 48-hour-period after fibronolytic therapy in patients who underwent PCI after fibrinolysis (2).

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.
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Most Read Articles
Yesterday
Exposure to corticosteroids in patients with autoimmune hepatitis (AIH) appears to contribute to increased risks of cataract, diabetes and bone fractures, a study has found. Notably, the fracture risk is elevated at low doses, while the risk of adverse events overall is dose-dependent and is reversible.
2 days ago
Monotherapy with tocilizumab (TCZ) shows good tolerability profile and results in remission in most patients with polymyalgia rheumatica (PMR) despite the absence of glucocorticoids, according to the 2-year results of a single-centre, open‐label pilot study.
28 Sep 2019
Clostridium difficile (CD) infection remains high in patients with acute myeloid leukaemia (AML) or myelodysplasia syndrome (MDS) undergoing allogeneic haematopoietic stem cell transplantation (alloHCT), a recent study has shown. Moreover, patients with CD infection appear to have a significantly lower overall survival.
Roshini Claire Anthony, 5 days ago

Patients with type 2 diabetes (T2D) and severe obesity may have a greater chance of complete T2D remission 1 year after gastric bypass rather than sleeve gastrectomy, according to results of the Oseberg* trial.