The American College of Cardiology and the American Heart Association recommend clopidogrel (Plavix) in addition to aspirin for patients with acute coronary syndrome (ACS) (grade A recommendation [consistent high-quality evidence]). Recently the Study of Platelet Inhibition and Patient Outcomes (PLATO) compared ticagrelor (Brilinta), a new platelet aggregation inhibitor, to clopidogrel in 18,624 ACS patients also treated with aspirin. Patients were randomized to ticagrelor (180 mg loading dose then 90 mg twice daily) vs. clopidogrel (300-600 mg loading dose then 75 mg daily) and followed for 12 months. The ticagrelor group had significantly lower all-cause mortality (4.5% vs. 5.9%, p < 0.001, NNT 72), vascular mortality (4% vs. 5.1%, p = 0.001, NNT 91), and myocardial infarction rate (5.8% vs. 6.9%, p = 0.005, NNT 91) (level 2 [mid-level] evidence), with no significant difference in major bleeding (11.6% vs. 11.2%) or stroke (1.5% vs. 1.3%). Premature discontinuation rates were high for both groups (23.4% vs. 21.5%), and withdrawal for adverse events was higher in the ticagrelor group (7.4% vs. 6.0%, p < 0.001, NNH 71) (N Engl J Med 2009 Sep 10;361(11):1045). Ticagrelor is not yet approved by the US Food and Drug Administration (FDA).

For more information, see the Antiplatelet agents for acute coronary syndrome topic in DynaMed.