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Interesting to see the POPular AGE trial published in @lancet today providing randomized data to validate our findings from a large Canadian registry study published in @JAMAInternalMed last month
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2758798 1/
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2758798 1/
2/ POPular AGE was an open-label RCT (n=1002 in ITT analysis) of comparing clopidogrel vs ticagrelor in patients 70+ y/o with NSTE-ACS (~1/2 treated with PCI w/ 2nd gen drug-eluting stents). 2 co-1o outcomes: PLATO major+minor bleed; "net benefit" (composite death/MI/stroke/bleed
3/ More patients prematurely stopped or switched from ticagrelor (47%) vs clopidogrel (22%). Top 3 reasons for ticagrelor D/C were dyspnea, bleeding & OAC start. As a result, median duration was shorter in ticagrelor group (324 vs 365 days)
4/ Outcomes: PLATO major/minor bleed lower w/ clop 18% vs ticag 24%. PLATO non-CABG major bleed also lower w/ clop (5% vs 9%), consistent with PLATO & our @JAMAInternalMed analysis. Clop non-inferior but not superior for the net benefit outcome (HR 0.82, 95% CI 0.66-1.03)
5/ Finally, composite of CV death/MI/stroke not significantly diff btw clop vs ticag (HR 0.92, 95% CI 0.64-1.34); again remarkably consistent w/ our @JAMAInternalMed analysis (adjusted HR 0.93, 0.80-1.09 for death/MI/ischemic stroke)
6/6 The emerging picture is that ASA+clopidogrel remains appropriate for many of our ACS patients, & that universal use of ASA+ticagrelor may lead to net harm. We need more widespread access to strategies to guide initial & maintenance post-ACS antithrombotic strategies.
