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Stroke Prevention with Ticagrelor in MI Patients

Circulation; ePub 2016 Aug 30; Bonaca, Goto, et al

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For high-risk patients with prior myocardial infarction (MI) who are at high risk for stroke, the addition of ticagrelor 60 mg twice daily significantly reduced this risk without an excess of hemorrhagic stroke, but with more major bleeding. This according to results from the PEGASUS-TIMI 54 trial of 14,112 patients assigned to placebo or ticagrelor 60 mg and followed for a median of 33 months. Researchers found:

• 213 patients had a stroke (85% ischemic).

• 18% of strokes were fatal; another 15% led to either moderate or severe disability at 30 days.

• Ticagrelor significantly reduced the risk of stroke (HR, 0.75), driven by a reduction in ischemic stroke (HR, 0.76).

• Hemorrhagic stroke occurred in 9 patients on placebo and 8 on ticagrelor.

• There was a marked reduction in ischemic stroke (HR, 0.66) in a meta-analysis across 4 placebo-controlled trials of more intensive antiplatelet therapy in 44,816 patients with coronary disease.

Citation: Bonaca MP, Goto S, Bhatt DL, et al. Prevention of stroke with ticagrelor in patients with prior myocardial infarction. [Published online ahead of print August 30, 2016]. Circulation. doi:10.1161/CIRCULATIONAHA.116.024637.

Commentary: Stroke affects approximately 800,000 people per year in the US, and individuals who have had prior MIs are at increased risk of developing a stroke. Previous studies have shown that ticagrelor reduces the composite endpoint of cardiovascular death, MI or stroke by approximately 15% when added to aspirin in individuals who have had a prior MI. The 25% reduction in ischemic stroke with no significant increase in hemorrhagic stroke is notable, though there was an increase of approximately 130% in major bleeding, primarily GI bleeds. It is important to recognize that in the setting of a prior stroke dual antiplatelet therapy has not shown consistent benefit in decreasing the risk of future stroke and has shown increased rates of intracranial hemorrhage.1 In a post-MI setting, in patients without prior stroke, this large study shows a benefit of ticagrelor in decreasing the risk of first stroke. —Neil Skolnik, MD

1. Diener HC, Weber R. Clopidogrel added to aspirin adds no benefit but bleeding risk in patients with recent lacunar stroke. Stroke. 2013;44:861–863. doi:10.1161/STROKEAHA.112.680751.

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