Hinda and Arthur Marcus Institute for Aging Research Hebrew SeniorLife Boston MA.
Section of Cardiovascular Medicine Boston Medical Center Boston MA.
J Am Heart Assoc. 2024 Aug 6;13(15):e034529. doi: 10.1161/JAHA.124.034529. Epub 2024 Jul 26.
Ticagrelor is recommended over clopidogrel in acute coronary syndrome based on the results of the PLATO (Study of Platelet Inhibition and Patient Outcomes) trial. We aimed to emulate PLATO in older adults with and without frailty and with acute coronary syndrome treated with percutaneous coronary intervention.
We created a new-user cohort of Medicare fee-for-service beneficiaries aged ≥65 years hospitalized for acute coronary syndrome from 2014 to 2018 and initiated ticagrelor or clopidogrel following percutaneous coronary intervention. Frailty was defined using a validated claims-based frailty index ≥0.25. Coprimary outcomes were major adverse cardiovascular events and major bleeding. Follow-up began on the date of first outpatient prescription for ticagrelor or clopidogrel and ended on the earliest date for an outcome event, death, discontinuation of the index drug, or disenrollment from Medicare. The study included 42 843 older adults; 23% were frail. After propensity score matching, the rates of major adverse cardiovascular events per 100 person-years comparing ticagrelor versus clopidogrel groups were 7.8 and 7.3 in the frail cohort (hazard ratio [HR], 1.07 [95% CI, 0.84-1.36]) and 3.7 and 4.2 in the nonfrail cohort (HR, 0.87 [95% CI, 0.75-1.02]). The corresponding rates of major bleeding were 4.3 and 3.8 in the frail cohort (HR, 1.12 95% CI, [0.80-1.56]) and 2.2 and 1.8 in the nonfrail cohort (HR, 1.22 [95% CI, 0.98-1.51]).
There was a trend toward a modest reduction in risk of major adverse cardiovascular events and a trend toward a modest increase in risk of major bleeding with ticagrelor compared with clopidogrel in the nonfrail cohort. There was insufficient evidence for the benefit of ticagrelor in frail older adults.
基于 PLATO（血小板抑制和患者结局研究）试验的结果，替格瑞洛被推荐用于急性冠脉综合征优于氯吡格雷。我们旨在模拟 PLATO 试验在接受经皮冠状动脉介入治疗的伴有或不伴有衰弱的老年急性冠脉综合征患者中的效果。
我们创建了一个新的医疗保险付费服务受益人的新用户队列，这些人年龄在 65 岁及以上，因急性冠脉综合征于 2014 年至 2018 年住院，并在经皮冠状动脉介入治疗后开始使用替格瑞洛或氯吡格雷。衰弱是通过使用经过验证的基于索赔的衰弱指数≥0.25 来定义的。主要复合结局是主要心血管不良事件和主要出血。随访从首次门诊开替格瑞洛或氯吡格雷处方之日开始，至最早发生结局事件、死亡、停用索引药物或退出医疗保险之日结束。该研究纳入了 42843 名老年人；其中 23%的人衰弱。在倾向评分匹配后，与氯吡格雷相比，替格瑞洛组在衰弱组的每 100 人年主要心血管不良事件发生率为 7.8%和 7.3%（风险比[HR]，1.07[95%CI，0.84-1.36]），在非衰弱组为 3.7%和 4.2%（HR，0.87[95%CI，0.75-1.02]）。相应的大出血发生率在衰弱组为 4.3%和 3.8%（HR，1.12[95%CI，0.80-1.56]），在非衰弱组为 2.2%和 1.8%（HR，1.22[95%CI，0.98-1.51]）。
与氯吡格雷相比，替格瑞洛在非衰弱队列中降低主要心血管不良事件风险的趋势较小，增加大出血风险的趋势较小。替格瑞洛在衰弱的老年患者中获益的证据不足。
