Ticagrelor Prescribed Less Frequently than other Antiplatelet Agents Overall, but Used More Often in Higher-Risk Patients

A recent study of thienopyridine use among patients who had undergone percutaneous coronary intervention (PCI) in a large hospital network found that the antiplatelet drug ticagrelor was more frequently prescribed in higher risk, less stable patients.

Amrita Karve, MD, and colleagues presented findings from the study “Contemporary Use of Ticagrelor in Interventional Practice: Insights From BMC2” during a poster session at the 2013 American Heart Association Scientific Sessions. In their introductory text, the authors noted that ticagrelor and prasugrel have “enhanced anti-ischemic efficacy and increased bleeding compared with clopidogrel” and have been approved for patients with acute coronary syndromes (ACS). Yet, despite the availability of these alternatives to clopidogrel, “there are no data on the contemporary use of ticagrelor.”

To investigate the clinical use of ticagrelor and find out more about the demographics of the patients for whom it is prescribed, the authors analyzed data from 43,167 patients who had percutaneous coronary intervention at one of the 47 Michigan hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry.

They reported that 75.7% (n=32,678) of patients were treated with clopidogrel, 21.7% (n=9,380) received prasugrel, and 2.6% (n=1,109) of patients received treatment with ticagrelor.

Ticagrelor was used in a majority of hospitals (32) in the registry, but frequency of treatment varied widely between hospitals: ticagrelor use ranged from 0.5% to 15.9 % of total discharges. According to the authors, patients who received treatment with ticagrelor tended to be female (34.2% received ticagrelor vs. 26.6% for prasugrel), older (mean age 64.5 years for ticagrelor vs. 59.1 years for prasugrel), and white (92.2% vs. 89.5%).

More patients treated with ticagrelor had a prior history of coronary artery bypass graft (CABG) compared to patients who received prasugrel (16.1% vs. 12.8%). Patients who received ticagrelor were also more likely to have presented with ST-segment elevation myocardial infarction (STEMI) or equivalent compared to their counterparts who received prasugrel (21.8% vs. 18.2%).

Patients treated with ticagrelor were also more likely to have had cardiac arrest within 24 hours of admission compared to prasugrel patients (2.3% vs. 1.4%), heart failure within the previous two weeks (6.9% vs. 5.3%), and have received an intra-aortic balloon pump (2.3% vs. 1.5%).

The authors also wrote that “compared with prasugrel, the predicted risk of contrast nephropathy (2.6% vs. 1.6%), transfusion (4.6% vs. 3.5%), and death (1.3% vs. 0.6%) was higher for ticagrelor (p <0 .001 for all).”

Based on these data, the authors concluded that “Ticagrelor use is low for patients undergoing PCI. Compared to prasugrel, ticagrelor is prescribed to a less stable, higher risk population, and 1 in 5 patients on ticagrelor did not have ACS.”