title: Ticagrelor versus clopidogrel in patients with acute coronary syndromes and a history of stroke or transient ischemic attack.
abstract: BACKGROUND
  Patients with acute coronary syndromes and history of stroke or transient ischemic attack (TIA) have an increased rate of recurrent cardiac events and intracranial hemorrhages.
  
  
  RESULTS
  We evaluated treatment effects of ticagrelor versus clopidogrel in patients with acute coronary syndrome with and without a history of prior stroke or TIA in the PLATelet inhibition and patient Outcomes (PLATO) trial. Of the 18 624 randomized patients, 1152 (6.2%) had a history of stroke or TIA. Such patients had higher rates of myocardial infarction (11.5% versus 6.0%), death (10.5% versus 4.9%), stroke (3.4% versus 1.2%), and intracranial bleeding (0.8% versus 0.2%) than patients without prior stroke or TIA. Among patients with a history of stroke or TIA, the reduction of the primary composite outcome and total mortality at 1 year with ticagrelor versus clopidogrel was consistent with the overall trial results: 19.0% versus 20.8% (hazard ratio, 0.87; 95% confidence interval, 0.66-1.13; interaction P=0.84) and 7.9% versus 13.0% (hazard ratio, 0.62; 95% confidence interval, 0.42-0.91). The overall PLATO-defined bleeding rates were similar: 14.6% versus 14.9% (hazard ratio, 0.99; 95% confidence interval, 0.71-1.37), and intracranial bleeding occurred infrequently (4 versus 4 cases, respectively).
  
  
  CONCLUSIONS
  Patients with acute coronary syndrome with a prior history of ischemic stroke or TIA had higher rates of clinical outcomes than patients without prior stroke or TIA. However, the efficacy and bleeding results of ticagrelor in these high-risk patients were consistent with the overall trial population, with a favorable clinical net benefit and associated impact on mortality.
  
  
  BACKGROUND
  URL: http://www.clinicatrials.gov. Unique identifier: NCT00391872.
authors.affiliation: Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden. Stefan.James@ucr.uu.se
authors.forename: Stefan K
authors.initials: SK
authors.lastname: James
authors.forename: Robert F
authors.initials: RF
authors.lastname: Storey
authors.forename: Nardev S
authors.initials: NS
authors.lastname: Khurmi
authors.forename: Steen
authors.initials: S
authors.lastname: Husted
authors.forename: Matyas
authors.initials: M
authors.lastname: Keltai
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.forename: Juan
authors.initials: J
authors.lastname: Maya
authors.forename: Joao
authors.initials: J
authors.lastname: Morais
authors.forename: Renato D
authors.initials: RD
authors.lastname: Lopes
authors.forename: Jose C
authors.initials: JC
authors.lastname: Nicolau
authors.forename: Prem
authors.initials: P
authors.lastname: Pais
authors.forename: Dimitar
authors.initials: D
authors.lastname: Raev
authors.forename: Jose L
authors.initials: JL
authors.lastname: Lopez-Sendon
authors.forename: Susanna R
authors.initials: SR
authors.lastname: Stevens
authors.forename: Richard C
authors.initials: RC
authors.lastname: Becker
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000401:mortality*; D000241:Adenosine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D000368:Aged; D002545:Brain Ischemia / Q000401:mortality; D000077144:Clopidogrel; D005260:Female; D006801:Humans; D020300:Intracranial Hemorrhages / Q000401:mortality; D002546:Ischemic Attack, Transient / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage / Q000009:adverse effects; D012307:Risk Factors; D020521:Stroke / Q000401:mortality*; D000077486:Ticagrelor; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D058921:Purinergic P2Y Receptor Antagonists; D000077144:Clopidogrel; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine