Cor Vasa 2018, 60(2):e127-e132 | DOI: 10.1016/j.crvasa.2017.07.004

The mortality benefit seen with the newer more potent oral P2Y12 inhibitors prasugrel and ticagrelor over clopidogrel is dependent on the underlying risk: A class effect as suggested by a meta-regression analysis

J. Wouter Jukema^a,*, Hannes Alber^b,c, Petr Widimský^d

^a Department of Cardiology C5-P, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, Nizozemsko

^b Department for Internal Medicine and Cardiology, Clinic Klagenfurt at Wörthersee, Feschingstrasse 11, 9020 Klagenfurt am Wörthersee, Rakousko

^c Karl Landsteiner Institute for Interdisciplinary Science, Reha Zentrum Münster in Tirol, 6232 Münster, Rakousko

^d Kardiocentrum 3. lékařské fakulty Univerzity Karlovy a Fakultní nemocnice Královské Vinohrady, Šrobárova 50, 100 34 Praha 10, Česká republika

Background: The two newer oral P2Y12 inhibitors prasugrel and ticagrelor have proven superior to clopidogrel in the treatment of acute coronary syndrome (ACS). The extent to which the reduction in mortality seen with ticagrelor is confined to this particular agent is hard to judge by simply looking at the overall study results as the study populations were composed of different cohorts at substantially different risk of death.

Methods: A meta-regression technique was applied to 12 distinctive patient cohorts, six for each of prasugrel and ticagrelor, to investigate differential effects on mortality of P2Y12 inhibitors.

Results: Data for the analysis cohorts, totalling 37,372 patients, were extracted from publications and cover a widely comparable spectrum of patient types, defined by the type of ACS and treatment strategy. The meta-regression lines for cardiovascular mortality with prasugrel or ticagrelor (each versus clopidogrel), as well as for both agents pooled, indicate a linear relationship with increasing benefit seen with higher underlying risk (p = 0.007, 0.021 and 0.003, and R2 = 0.87, 0.77 and 0.62, respectively).

Conclusions: In the ACS patients studied, we found a mortality benefit with the two newer oral P2Y12 inhibitors prasugrel and ticagrelor when compared with clopidogrel, which increases progressively as the underlying risk of death increases. This appears to be a class effect for these two newer agents.

Keywords: Acute coronary syndrome; Meta-regression; Mortality; Prasugrel; P2Y12 inhibitor; Ticagrelor

Received: June 8, 2017; Accepted: July 18, 2017; Published: April 1, 2018  Show citation