The Role of Ticagrelor in STEMI Fibrinolytic and Its Rationale to Utilize for Indonesian Patients
Worldwide, ischemic heart disease is the most common cause of death and its frequency is increasing. ST-segment elevation myocardial infarction or STEMIis as form of ischemic heart disease with the highest mortality rate.
Based on ESC (European Society of Cardiology) guideline 2017 for STEMI management, reperfusion therapywhich is primary PCI strategy is recommended over fibrinolysis within induced timeframes, but if timely primary PCI cannot be performed after STEMI diagnosis, fibrinolytic therapy is recommended within 12 hours of symptom onset in patients without contraindications. In fibrinolytic therapy, oral aspirin should be given, and Clopidogrel is indicated as an addition to aspirin. Although Clopidogrel is a recommended P2Y12receptor inhibitorin fibrinolytic therapy,PERKI guideline 2018 in ACS management also mention thatswitching to Ticagrelor can be considered in patients whowillundergo PCI treatmentafter fibrinolytic.
In PLATO study, patients who have acute coronary syndrome with or without ST-segment elevation, treatment with ticagrelor as compared with clopidogrel significantly reduced the rate of death from vascular causes, myocardial infarction, or stroke. However, patients who received fibrinolytic therapy within 24 hours before randomization were excluded. WhileinSET-FAST study, Ticagrelor provides more prompt and potent platelet inhibition compared with Clopidogrel in patients undergoing PCI within 24 hours of receiving fibrinolysis for STEMI. TREAT study was conducted to evaluate the safety of ticagrelor in STEMI patients receiving fibrinolytic therapy within 24 hours.TREAT study concluded, at 30 days observation, in patients younger than 75 years with STEMI, delayed administration of Ticagrelor after fibrinolytic therapy was noninferior to Clopidogrel for TIMI major bleeding.
Based on the result from PLATO study and preliminary TREAT study result on 30 days, the use of Ticagrelor within 24 hours after fibrinolytic therapy can be considered with comparable safety profile to Clopidogrel.
Keywords: STEMI, fibrinolysis, ticagrelor
2. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal. 2018;39:119-177.
3. Perhimpunan Dokter Spesialis Kardovaskular Indonesia (PERKI). Pedoman Tatalaksana Sindrom Koroner Akut. 4th edition. 2018
4. Wallentin, L. et al. Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndrome. N Engl J Med. 2009;361:1045-57.
5. Steg, P.G. et al. Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndrome Intended for Reperfusion With Primary Percutaneous Coronary Intervention: A Platelet Inhibiton and Patient Outcomes (PLATO) Trial Subgroup Analysis. Circulation. 2010;122:2131-2141.
6. Dehghani, P. et al. Effects of ticagrelor versus clopidogrel on platelet function in fibrinolytic-treated STEMI patients undergoing early PCI. Am Heart J. 2017;192:105-12.
7. Berwanger, O. et al. Ticagrelor vs Clopidogrel After Fibrinolytic Therapy in Patients With ST-Elevation Myocardial Infarction. JAMA Cardiol. 2018;3(5):391-399.
Copyright (c) 2019 Indonesian Journal of Cardiology
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).