Ticagrelor or prasugrel versus clopidogrel in patients with atrial fibrillation undergoing percutaneous coronary intervention for myocardial infarction

The efficacy and safety of ticagrelor or prasugrel versus clopidogrel in patients with atrial fibrillation (AF) on oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) for myocardial infarction have not been established. Nationwide cohort study of patients on OAC for AF who underwent PCI for myocardial infarction from 2011 through 2019 and were prescribed a P2Y12 inhibitor at discharge. The primary efficacy outcome was major adverse cardiovascular events (MACE), defined as a composite of death from any cause, stroke, recurrent myocardial infarction, or repeat revascularization. The primary safety outcome was cerebral, gastrointestinal, or urogenital bleeding requiring hospitalization. Absolute and relative risks for outcomes at 1 year were calculated through multivariable logistic regression with average treatment effect modeling. Outcomes were standardized for the individual components of CHA2DS2-VASc and HAS-BLED scores as well as type of OAC, aspirin, and proton pump inhibitor use. We included 2259 patients of whom 1918 (84.9%) were prescribed clopidogrel and 341 (15.1%) ticagrelor or prasugrel. The standardized risk of MACE was significantly lower in the ticagrelor or prasugrel group compared with the clopidogrel group (standardized absolute risk, 16.4% vs. 19.4%; relative risk, 0.84, 95% confidence interval, 0.70-0.98; P=0.02), while the risk of bleeding did not differ (standardized absolute risk, 5.5% vs. 5.1%; relative risk, 1.07, 95% confidence interval, 0.73-1.41; P=0.69). In patients with AF on OAC who underwent PCI for myocardial infarction, treatment with ticagrelor or prasugrel versus clopidogrel was associated with reduced ischemic risk, without a concomitantly increased bleeding risk.