Ticagrelor versus clopidogrel after percutaneous coronary intervention for acute coronary syndrome: A meta-analysis and meta-regression of randomized controlled trials

Abstract

Acute coronary syndrome (ACS) arises from abrupt myocardial ischemia, most commonly due to coronary thrombosis. After percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) with aspirin and P2Y₁₂ inhibitor is standard. Clopidogrel, a widely used P2Y₁₂ inhibitor, shows reduced efficacy in some patients due to genetic variability. Ticagrelor has emerged as a potential alternative in DAPT for ACS post-PCI. The aim of this study was to evaluate the efficacy and safety of ticagrelor compared to clopidogrel as DAPT for ACS patients post-PCI through outcomes of cardiovascular death, myocardial infarction, stent thrombosis, target revascularization, dyspnea, and major bleeding. A systematic search was conducted through databases such as PubMed, Scopus, Cochrane, Epistemonikos, ClinicalTrials.gov, ProQuest, Scilit, and Google Scholar. The quality of the included studies was assessed using the Cochrane RoB 2.0 tool. Meta-analyses were conducted using a random-effects model, and pooled risk ratios (RR) with 95% confidence intervals (CIs) were analyzed using RevMan 5.4 and RStudio. Eight RCTs (n=1,726) showed that ticagrelor significantly reduced the incidence of myocardial infarction (RR=0.44; 95%CI: 0.21–0.91; p=0.03; I²=0%), stent thrombosis (RR=0.30; 95%CI: 0.14–0.66; p=0.0027; I²=0%), and target revascularization (RR=0.47; 95%CI: 0.26–0.83; p=0.0098; I²=0%).  No significant difference was observed in cardiovascular death (RR=0.54; 95%CI: 0.27–1.06;  p=0.00733; I²=0%). In terms of safety, dyspnea was more frequently reported in the ticagrelor group (RR=6.20; 95%CI: 1.10–35.04; p=0.039; I²=0%). In addition, no significant difference was found in the incidence of major bleeding (RR=1.05; 95%CI: 0.43–2.54;  p=0.9176; I²=0%). Ticagrelor appears to be more effective than clopidogrel as part of DAPT in patients with ACS post-PCI, without an increase in serious adverse events. Further studies are needed with longer follow-up periods, more diverse patient populations, and broader adverse events.