Department of Medicine (Huddinge), Karolinska Institutet; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (K.S.).
Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA (M.E.M.-R.).
Circulation. 2020 Nov 3;142(18):1700-1708. doi: 10.1161/CIRCULATIONAHA.120.050645. Epub 2020 Sep 1.
The comparative efficacy and safety of ticagrelor versus clopidogrel in older patients with myocardial infarction (MI) has received limited study.
We performed an observational analysis of all patients ≥80 years (n=14 005) who were discharged alive with aspirin combined with either clopidogrel (60.2%) or ticagrelor (39.8%) after a MI between 2010 and 2017 registered in the national registry SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies). Inverse probability treatment weighting was used in Cox regression models to adjust for differences in demographics, in-hospital therapies, and medications. The primary ischemic outcome (death, MI, or stroke), and bleeding were obtained from national registries at 1 year. A sensitivity analysis in <80-year-old patients was performed.
In patients ≥80 years, the incidence of the primary ischemic outcome (hazard ratio [HR], 0.97 [95% CI, 0.88-1.06]) was similar for ticagrelor- and clopidogrel-treated patients. Ticagrelor was associated with a 17% and 48% higher risk of death (HR, 1.17 [95% CI, 1.03-1.32]) and bleeding (HR, 1.48 [95% CI, 1.25-1.76]), but a lower risk of MI (HR, 0.80 [95% CI, 0.70-0.92]) and stroke (HR, 0.72 [95% CI, 0.56-0.93]). In <80-year-old patients, the incidence of the primary ischemic outcome was 17% (HR, 0.83 [95% CI, 0.77-0.89]) lower with ticagrelor. Ticagrelor was associated with 15% (HR, 0.85 [95% CI, 0.76-0.96]) lower risk of death, 32% higher risk of bleeding (HR, 1.32 [95% CI, 1.18-1.47]), but lower risk of MI (HR, 0.82 [95% CI, 0.75-0.91]) and stroke (HR, 0.82 [95% CI, 0.69-0.98]).
Ticagrelor use among elderly patients with MI was associated with higher risk of bleeding and death compared with clopidogrel. A randomized study of ticagrelor versus clopidogrel in the elderly is needed.
替格瑞洛与氯吡格雷在老年心肌梗死（MI）患者中的疗效和安全性比较研究较少。
我们对 2010 年至 2017 年期间在全国 SWEDEHEART 注册登记的所有年龄≥80 岁（n=14005）、出院时存活且接受阿司匹林联合氯吡格雷（60.2%）或替格瑞洛（39.8%）治疗的 MI 患者进行了一项观察性分析。采用逆概率治疗加权 Cox 回归模型调整人口统计学、院内治疗和药物治疗的差异。主要缺血结局（死亡、MI 或卒中）和出血情况通过国家登记处于 1 年时获得。在年龄<80 岁的患者中进行了敏感性分析。
在年龄≥80 岁的患者中，替格瑞洛和氯吡格雷治疗患者的主要缺血结局发生率（风险比[HR]，0.97[95%CI，0.88-1.06]）相似。替格瑞洛与死亡（HR，1.17[95%CI，1.03-1.32]）和出血（HR，1.48[95%CI，1.25-1.76]）风险增加 17%和 48%相关，但 MI（HR，0.80[95%CI，0.70-0.92]）和卒中（HR，0.72[95%CI，0.56-0.93]）风险降低。在年龄<80 岁的患者中，替格瑞洛使主要缺血结局的发生率降低了 17%（HR，0.83[95%CI，0.77-0.89]）。替格瑞洛与死亡风险降低 15%（HR，0.85[95%CI，0.76-0.96]）相关，出血风险增加 32%（HR，1.32[95%CI，1.18-1.47]），但 MI（HR，0.82[95%CI，0.75-0.91]）和卒中（HR，0.82[95%CI，0.69-0.98]）风险降低。
与氯吡格雷相比，替格瑞洛在老年 MI 患者中的应用与出血和死亡风险增加相关。需要进行替格瑞洛与氯吡格雷在老年人中的随机研究。
