Ticagrelor vs. Clopidogrel When Co-administered With Bivalirudin in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Background The optimal perioperative antithrombotic strategy for patients with acute coronary syndrome (ACS) during percutaneous coronary intervention (PCI) remains controversial. Objectives To determine the safety and effectiveness of bivalirudin plus ticagrelor versus bivalirudin plus clopidogrel in patients with ACS submitted to PCI in the real world. Methods Between March 2016 and March 2019, 7 234 patients with ACS, who had undergone PCI and received bivalirudin peri-procedurally and prescribed ticagrelor or clopidogrel, were enrolled in a single-center, all comer, modern retrospective cohort study. Incidence rate of 12-month ischemia (cardiac death, myocardial infarction (MI), or stroke), all-cause death, Bleeding Academic Research Consortium (BARC) type 2,3,5 bleeding and BARC type 3,5 bleeding were compared between different groups. Results In total, 4 960 of patients received bivalirudin plus clopidogrel and 2 274 of patients received bivalirudin plus ticagrelor. Compared with bivalirudin plus clopidogrel, bivalirudin plus ticagrelor was associated with lower ischemic events (1.74% vs. 2.84%, RR: 0.61, 95%CI, 0.41-0.91, p = 0.02) and stroke (0.05% vs. 1.01%, p < 0.001) within 12 months after PCI without excessive risk of bleeding (BARC type 2,3,5 bleeding: 4.49% vs. 3.76%, p = 0.22; BARC type 3,5 bleeding: 2.84% vs. 2.02%, p = 0.08). The beneficial effects of bivalirudin plus ticagrelor were consistent among subgroups. Conclusions As an initial treatment strategy, bivalirudin plus ticagrelor could reduce the 12-month risk of ischemic events compared with bivalirudin plus clopidogrel significantly without increasing the bleeding risk in ACS patients undergone PCI.