title: Ticagrelor in Triple Antithrombotic Therapy: Predictors of Ischemic and Bleeding Complications.
abstract: BACKGROUND
  Patients on dual antiplatelet therapy following percutaneous coronary intervention often have indications for concurrent oral anticoagulation or triple antithrombotic therapy (TT). Although TT may decrease ischemic complications, it may confer increased bleeding risk.
  
  
  OBJECTIVE
  We hypothesize that the use of ticagrelor in TT is associated with higher risk of complications; accordingly, we sought to determine predictors of complications in patients on TT.
  
  
  METHODS
  Patients discharged on TT after percutaneous coronary intervention were followed prospectively for 12 months. The primary endpoint was a composite of ischemic (death, myocardial infarction, stroke) and major bleeding complications or net adverse clinical event (NACE). A major secondary endpoint was BARC (Bleeding Academic Research Consortium) types 2, 3, or 5 bleeding. Outcomes were compared between ticagrelor- and clopidogrel-treated patients. Multivariable analyses were performed to elucidate predictors of complications.
  
  
  RESULTS
  Twenty-seven of 152 patients discharged on TT were on ticagrelor. NACE occurred in 52% of patients and BARC 2, 3, or 5 bleeding occurred in 18%. There was no difference in the primary or secondary outcome between ticagrelor vs clopidogrel subgroup. On logistic regressions, use of TT in patients with acute coronary syndrome (P = 0.002) and bridging in with ticagrelor (P = 0.02) were associated with increased NACE. Low estimated glomerular filtration rate was an independent predictor of bleeding (P = 0.03).
  
  
  CONCLUSIONS
  The risk of bleeding and ischemic complications among patients on TT is similar between those on ticagrelor and clopidogrel. However, caution with use of bridging anticoagulation should be taken when using ticagrelor.
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Angel
authors.initials: A
authors.lastname: Fu
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Kuljit
authors.initials: K
authors.lastname: Singh
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Joseph
authors.initials: J
authors.lastname: Abunassar
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Nikita
authors.initials: N
authors.lastname: Malhotra
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Michel
authors.initials: M
authors.lastname: Le May
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Marino
authors.initials: M
authors.lastname: Labinaz
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Christopher
authors.initials: C
authors.lastname: Glover
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Marquis
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Froeschl
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Alexander
authors.initials: A
authors.lastname: Dick
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Hibbert
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Aun-Yeong
authors.initials: AY
authors.lastname: Chong
authors.affiliation: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors.forename: Derek Y F
authors.initials: DY
authors.lastname: So
mesh_terms: D000241:Adenosine / Q000009:adverse effects / Q000031:analogs & derivatives*; D016009:Chi-Square Distribution; D002986:Clinical Trials as Topic; D000077144:Clopidogrel; D004359:Drug Therapy, Combination; D005343:Fibrinolytic Agents / Q000009:adverse effects*; D006470:Hemorrhage / Q000139:chemically induced*; D006801:Humans; D016015:Logistic Models; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000517:prevention & control; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects* / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects*; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000517:prevention & control; D000077486:Ticagrelor; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine