The European Society of Cardiology (ESC) has given Brilinta (ticagrelor tablets; AstraZeneca) a Class I recommendation in its updated “Guidelines on the Management of Acute Myocardial Infarction in Patients Presenting with Persistent ST-Segment Elevation (STEMI).”

For primary percutaneous coronary intervention (PCI), the guidelines now recommend ticagrelor with no restrictions for STEMI patients (Class I; LOE B). Prasugrel, (Class I; LOE B), is recommended only for clopidogrel-naïve patients with no prior history of stroke/TIA and aged <75 years. Clopidogrel is recommended when prasugrel or ticagrelor are either not available or contraindicated. All of these recommendations are in combination with aspirin.

Ticagrelor plus aspirin, or prasugrel plus aspirin, are recommended (over clopidogrel plus aspirin) in patients treated with PCI (Class I: LOE A). Treatment with ticagrelor is recommended for up to 12 months. In addition, the guidelines recommend antiplatelet therapy with low dose aspirin after STEMI indefinitely.

The ESC guideline updates were based on data from PLATO (A Study of PLATelet Inhibition and Patient Outcomes), a large head-to-head patient outcomes study (n=18,624) of ticagrelor vs. clopidogrel, both given in combination with aspirin. Treatment with ticagrelor plus aspirin led to a greater reduction in the primary end point – a composite of CV death, myocardial infarction (MI), or stroke – compared to clopidogrel plus aspirin [9.8% vs. 11.7% at 12 months; 16% relative risk reduction (RRR); 95% CI, 0.77—0.92]. The difference in treatments was driven by CV death and MI with no difference in stroke. The PLATO study also demonstrated that treatment with ticagrelor for 12 months was associated with a 21% RRR in CV death [4% vs. 5.1%; 1.1% absolute risk reduction (ARR)] and a 16% RRR in MI compared to clopidogrel at 12 months (5.8% vs. 6.9%; 1.1% ARR).

Ticagrelor is an oral P2Y12 platelet inhibitor indicated to reduce the rate of thrombotic cardiovascular events in patients with acute coronary syndrome (unstable angina or non-ST-elevation myocardial infarction [MI] or ST-elevation MI). Ticagrelor is available as 90mg dosage strength tablets and is known under the trade Brilinta.

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