ACC 2013 Report – Ticagrelor has its largest effect in ACS patients with elevated troponin

Recent guidelines suggest that NSTEMI patients with elevated troponin levels are recommended for early invasive treatment, but a substantial proportion are still managed without an early invasive procedure. Patients with elevated levels of troponin show greater benefit from antithrombotic treatment in the acute stage.

In the PLATO trial, ticagrelor reduced CV death, MI, and stroke more effectively than clopidogrel in patients with acute coronary syndrome (ACS). At the AHA 2012 meeting, Lars Wallentin, MD, PhD, and colleagues evaluated outcomes in patients with NSTEMI to see whether levels of high-sensitivity troponin-T (hs-TnT) at study entry are associated with different outcomes managed with or without revascularization.

Of those patients with plasma samples available for biomarker determination, there were 5,357 patients with NSTEMI who were managed with revascularization and 4,589 patients who did not undergo revascularization during the index hospitalization. In the 5,011 invasively managed patients with elevated hs-TnT, ticagrelor reduced the composite of CV death, MI, and stroke from 11.2% to 8.5%.

In the 3,576 noninvasively managed patients with elevated hs-TnT, ticagrelor reduced the composite of CV death, MI, and stroke from 14.9% to 12.4%, mainly driven by a reduction in CV mortality. Event rates were very low in the 1,013 noninvasive NSTEMI patients with normal hs-TnT. Both invasive and noninvasive managed cohorts had no significant interaction of treatment with hs-TnT status.

In patients with NSTE-ACS and elevated hs-TnT, ticagrelor improves survival, reduces CV-related death and spontaneous and procedure-related MI in invasively managed patients, and reduces the composite of CV-related death and spontaneous MI in noninvasively managed patients. In patients without in-hospital revascularization and normal hs-TnT at entry, event rates were low and the benefits of ticagrelor were uncertain.

The results of this sub-study indicate that ticagrelor has its largest effect in ACS patients with elevated troponin, whether initially managed invasively or medically. This suggests hs-TnT might support tailoring of ticagrelor treatment to patients with NSTEMI.