Safety and Efficacy of Ticagrelor versus Clopidogrel in East Asian Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention Treated with Dual Antiplatelet Therapy: A Meta-Analysis of Randomized Controlled Trials

Introduction: The treatment strategy for dual antiplatelet therapy (DAPT) with ticagrelor has been controversial in East Asian patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Our meta-analysis aimed to demonstrate whether intensified antithrombotic regimens with ticagrelor plus aspirin have more beneficial effects and fewer adverse events compared to those of clopidogrel plus aspirin in East Asian patients with ACS undergoing PCI. Methods: We searched PubMed, Embase, Web of Science, Science Direct, Clinical Trial, Cochrane Library, and Chinese Clinical Trial Registry for randomized controlled trials (RCTs) comparing the efficacy of DAPT with ticagrelor or clopidogrel plus aspirin for secondary prevention of ACS in East Asian patients undergoing PCI. Risk ratios (RR) and 95% confidence intervals (CIs) were used as the metrics of choice for assessing treatment effect. The primary endpoint was bleeding events, and the secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE, including cardiovascular death, non-fatal myocardial infarction, and stroke), all-cause death, and definite/probable/possible stent thrombosis. The I-2 index was used to assess heterogeneity. Results: Six RCTs involving a total of 2,725 patients met the inclusion criteria. The incidence of all bleeding events with ticagrelor was higher than that with clopidogrel (RR, 1.65; 95%CI, 1.31-2.07), but the incidence of MACCE was not significantly different between the two groups (RR, 1.08; 95%CI, 0.54-2.16). All-cause death (RR, 1.10; 95%CI, 0.67-1.79), cardiovascular death (RR, 1.42; 95%CI, 0.68-2.98), non-fatal MI (RR, 0.92; 95%CI, 0.48-1.78), stroke (RR,1.00; 95%CI, 0.40-2.50), and stent thrombosis (RR, 0.76; 95%CI, 0.19-2.98) were not statistically different between the two groups. Conclusion: Ticagrelor increased the risk of bleeding and did not increase treatment efficacy compared to that of clopidogrel in the East Asian population who have ACS treated with PCI.