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Ticagrelor versus clopidogrel in orally anticoagulated patients with acute coronary syndrome undergoing percutaneous coronary intervention

Emilsson, Oskar Love LU orcid ; Mohammad, Moman A LU orcid ; van der Pals, Jesper LU ; Braun, Oscar LU ; Angerås, Oskar ; Jernberg, Tomas ; Zhou, Mikael LU ; von Koch, Sacharias LU orcid ; Erlinge, David LU orcid and Koul, Sasha LU (2026) In EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 22(10). p.575-584
Abstract

BACKGROUND: In patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) and who are treated with direct oral anticoagulants (DOACs), dual antithrombotic treatment without aspirin is recommended. Evidence comparing P2Y
12 inhibitor strategies in this setting is limited.

AIMS: This study aimed to compare outcomes with ticagrelor versus clopidogrel as part of dual antithrombotic treatment in ACS patients undergoing PCI.

METHODS: Using data from the SWEDEHEART registry, we conducted a cohort study including patients on dual antithrombotic treatment with ACS undergoing PCI between January 2014 and February 2022. Outcomes within one year were analysed using multivariate Cox... (More)

BACKGROUND: In patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) and who are treated with direct oral anticoagulants (DOACs), dual antithrombotic treatment without aspirin is recommended. Evidence comparing P2Y
12 inhibitor strategies in this setting is limited.

AIMS: This study aimed to compare outcomes with ticagrelor versus clopidogrel as part of dual antithrombotic treatment in ACS patients undergoing PCI.

METHODS: Using data from the SWEDEHEART registry, we conducted a cohort study including patients on dual antithrombotic treatment with ACS undergoing PCI between January 2014 and February 2022. Outcomes within one year were analysed using multivariate Cox regression to obtain adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for major adverse cardiovascular events (MACE; including mortality, myocardial infarction [MI], and stroke), all-cause mortality, clinically relevant bleeding, and MI.

RESULTS: A total of 3,708 patients were included (median age 76 years; 69% males; 40% ST-segment elevation myocardial infarction). At discharge, 1,170 (32%) received ticagrelor and 2,538 (68%) clopidogrel. For MACE, the unadjusted event rate was 16.7% in the ticagrelor group and 16.6% in the clopidogrel group (aHR 1.02, 95% CI: 0.84-1.23). Mortality occurred in 6.6% of patients treated with ticagrelor and 6.2% of those treated with clopidogrel (aHR 1.24, 95% CI: 0.91-1.69). Bleeding was 4.9% in the ticagrelor group compared with 3.7% in the clopidogrel group (aHR 1.53, 95% CI: 1.06-2.22). MI occurred in 10.4% of patients on ticagrelor and 11.2% of those on clopidogrel (aHR 0.90, 95% CI: 0.71-1.13).

CONCLUSIONS: In ACS patients on DOACs undergoing PCI, ticagrelor was associated with an increased risk of bleeding compared with clopidogrel, with no differences in MACE, mortality, or MI.

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; ; ; ; ; ; ; ; and
organization
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type
Contribution to journal
publication status
published
subject
keywords
Humans, Ticagrelor/therapeutic use, Male, Percutaneous Coronary Intervention/methods, Clopidogrel/therapeutic use, Female, Aged, Acute Coronary Syndrome/surgery, Platelet Aggregation Inhibitors/therapeutic use, Administration, Oral, Anticoagulants/administration & dosage, Registries, Treatment Outcome, Middle Aged, Aged, 80 and over, Purinergic P2Y Receptor Antagonists, Hemorrhage/chemically induced
in
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology
volume
22
issue
10
pages
575 - 584
publisher
Société Europa Edition
external identifiers
  • pmid:42137919
ISSN
1969-6213
DOI
10.4244/EIJ-D-25-01373
language
English
LU publication?
yes
id
5c6a17e6-3662-45a2-b091-c2fbd0f59485
date added to LUP
2026-05-16 15:35:41
date last changed
2026-05-18 06:41:26
@article{5c6a17e6-3662-45a2-b091-c2fbd0f59485,
  abstract     = {{<p>BACKGROUND: In patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) and who are treated with direct oral anticoagulants (DOACs), dual antithrombotic treatment without aspirin is recommended. Evidence comparing P2Y<br>
 12 inhibitor strategies in this setting is limited.<br>
 </p><p>AIMS: This study aimed to compare outcomes with ticagrelor versus clopidogrel as part of dual antithrombotic treatment in ACS patients undergoing PCI.</p><p>METHODS: Using data from the SWEDEHEART registry, we conducted a cohort study including patients on dual antithrombotic treatment with ACS undergoing PCI between January 2014 and February 2022. Outcomes within one year were analysed using multivariate Cox regression to obtain adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for major adverse cardiovascular events (MACE; including mortality, myocardial infarction [MI], and stroke), all-cause mortality, clinically relevant bleeding, and MI.</p><p>RESULTS: A total of 3,708 patients were included (median age 76 years; 69% males; 40% ST-segment elevation myocardial infarction). At discharge, 1,170 (32%) received ticagrelor and 2,538 (68%) clopidogrel. For MACE, the unadjusted event rate was 16.7% in the ticagrelor group and 16.6% in the clopidogrel group (aHR 1.02, 95% CI: 0.84-1.23). Mortality occurred in 6.6% of patients treated with ticagrelor and 6.2% of those treated with clopidogrel (aHR 1.24, 95% CI: 0.91-1.69). Bleeding was 4.9% in the ticagrelor group compared with 3.7% in the clopidogrel group (aHR 1.53, 95% CI: 1.06-2.22). MI occurred in 10.4% of patients on ticagrelor and 11.2% of those on clopidogrel (aHR 0.90, 95% CI: 0.71-1.13).</p><p>CONCLUSIONS: In ACS patients on DOACs undergoing PCI, ticagrelor was associated with an increased risk of bleeding compared with clopidogrel, with no differences in MACE, mortality, or MI.</p>}},
  author       = {{Emilsson, Oskar Love and Mohammad, Moman A and van der Pals, Jesper and Braun, Oscar and Angerås, Oskar and Jernberg, Tomas and Zhou, Mikael and von Koch, Sacharias and Erlinge, David and Koul, Sasha}},
  issn         = {{1969-6213}},
  keywords     = {{Humans; Ticagrelor/therapeutic use; Male; Percutaneous Coronary Intervention/methods; Clopidogrel/therapeutic use; Female; Aged; Acute Coronary Syndrome/surgery; Platelet Aggregation Inhibitors/therapeutic use; Administration, Oral; Anticoagulants/administration & dosage; Registries; Treatment Outcome; Middle Aged; Aged, 80 and over; Purinergic P2Y Receptor Antagonists; Hemorrhage/chemically induced}},
  language     = {{eng}},
  month        = {{05}},
  number       = {{10}},
  pages        = {{575--584}},
  publisher    = {{Société Europa Edition}},
  series       = {{EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology}},
  title        = {{Ticagrelor versus clopidogrel in orally anticoagulated patients with acute coronary syndrome undergoing percutaneous coronary intervention}},
  url          = {{http://dx.doi.org/10.4244/EIJ-D-25-01373}},
  doi          = {{10.4244/EIJ-D-25-01373}},
  volume       = {{22}},
  year         = {{2026}},
}