What is the role of ticagrelor (Brilinta) in the treatment of acute coronary syndrome (ACS)?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Answer

Ticagrelor (Brilinta) was approved by the US Food and Drug Administration in July 2011 and is the first reversible oral P2Y receptor antagonist. Results from the randomized PLATO (PLATelet inhibition and patient Outcomes) trial showed that ticagrelor provides faster, greater, and more consistent ADP-receptor inhibition than clopidogrel. [75]

In the PLATO trial, the difference between treatments on the composite resulted from effects on CV death and MI; each was statistically significant when considered as a secondary endpoint, and there was no beneficial effect on strokes. [75, 76, 77] For all-cause mortality, the benefit was also statistically significant of 9.8% for ticagrelor and 11.7% for clopidogrel (P = 0.0003) with a hazard ratio of 0.78.

Bleeding risk was assessed in the PLATO trial, and ticagrelor increased the overall risk of bleeding (major + minor) to a somewhat greater extent than did clopidogrel. [75] The increase was seen for non-CABG-related bleeding but not for CABG-related bleeding. Fatal and life-threatening bleeding rates were not increased.

In September 2015, the indication for ticagrelor was expanded to include use in patients with a history of MI more than 1 year previously. [78] Approval is based on the PEGASUS TIMI-54 study, a large-scale outcomes trial involving over 21,000 patients. [79] PEGASUS TIMI-54 investigated ticagrelor 60 mg twice daily plus low-dose aspirin, compared to placebo plus low-dose aspirin, for the long-term prevention of CV death, heart attack, and stroke in patients who had experienced an MI 1-3 years prior to study enrollment. In patients with an MI more than 1 year previously, treatment with ticagrelor significantly reduced the risk of CV death, MI, or stroke compared with placebo. [79]


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