Effectiveness of new antiplatelets in the prevention of recurrent myocardial infarction.

Objective: To compare ticagrelor and prasugrel with clopidogrel for recurrent fatal and non-fatal myocardial infarction (reMI) in real-life conditions.
Methods: Case-referent study using the Pharmacoepidemiological General Research eXtension (PGRx)-acute coronary syndrome (ACS) registry. Cases were patients with reMI from a cohort with index ACS or external to the cohort (same sites). Referents from the cohort, without recurrent event, were matched on index ACS type and date, age and sex with reMI cases. Multivariate conditional logistic regression assessed the OR (95% CI) for reMI associated with ticagrelor and prasugrel vs clopidogrel, adjusted for aspirin use and cardiovascular risk factors.
Results: 1047 cases and 2234 matched referents were included. Compared with clopidogrel, ticagrelor and prasugrel were associated with respective ORs of 0.65 (95% CI 0.52 to 0.81) and 0.71 (95% CI 0.53 to 0.96) for reMI occurrence. ORs for ticagrelor and prasugrel vs clopidogrel were: 0.50 (95% CI 0.38 to 0.67) and 0.66 (95% CI 0.45 to 0.95), 0.39 (95% CI 0.24 to 0.62) and 0.44 (95% CI 0.26 to 0.75), 0.63 (95% CI 0.43 to 0.92) and 1.20 (95% CI 0.69 to 2.07), 1.11 (95% CI 0.72 to 1.72) and 0.82 (95% CI 0.44 to 1.54) when index ACS was a first MI, a first ST-elevated MI (STEMI), a first non-STEMI and a recurrent ACS, respectively, and 0.63 (95% CI 0.45 to 0.87) and 0.77 (95% CI 0.41 to 1.45) for patients aged ≥70  years.
Conclusions: This real-world study showed a significant reduction of reMI with new antiplatelets compared with clopidogrel, ticagrelor being associated with a greater decrease of risk notably for first, either STEMI or non-STEMI. The larger magnitude of effect may be attributed to potential residual confounding or higher effectiveness compared with efficacy reported in trials (EMA Post Authorisation Study Registry Number EUPAS5905).
Competing Interests: Competing interests: LG-B is currently employed by PGRx, a company susceptible of collaborating with virtually all the pharmaceutical companies worldwide. NDa declares having received financial support from Abbott France, Amgen SAS, AstraZeneca, Bayer Healthcare SAS, Boehringer Ingelheim France, Bristol-Myers Squibb, GlaxoSmithKline France, Lilly France SAS, MSD France, Novo Nordisk, Pierre Fabre, Re-Imagine Health Agency, Sanofi-Aventis France and Servier during the conduct of the study. JD declares having received personal fees for participating in Scientific Boards from AstraZeneca, Bayer and MSD. BF reports personal fees from AstraZeneca during the conduct of the study. AF, OM, FL, FG and NDe declare no conflict of interest. YC declares having received financial support for participating in Scientific Boards and consulting for Bayer, Boehringer, Novartis, Pfizer and Servier outside the submitted work. LB declares having received financial support in the form of grants and/or personal fees from AstraZeneca during the conduct of the study and also outside the submitted work. EP declares having received fees for lectures and/or consulting from Amgen, AstraZeneca, Bayer, BMS, Daiichi-Sankyo, Lilly, MSD, The Medicine Company, Sanofi and Servier. JB declares having received financial support from Association pour le Développement de l’Enseignement et des Recherches auprès des universités des centres de recherches et des entreprises d’Aquitaine, AstraZeneca, Servier and LASER during the conduct of the study. LA is chairman and stock owner in Analytica LASER, a consultancy susceptible of collaborating with virtually all the pharmaceutical companies worldwide. PGRx has no commercial interests in any of the products studied. Members of the PGRx network have no interest in any drugs or other factors studied using data collected using PGRx.
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