(983) Goal P2Y12 Reaction Unit Attainment: Clopidogrel vs Ticagrelor Post Neuroendovascular Intervention

Introduction: Trial data using antiplatelets in the post interventional neuroradiology setting is limited. Additionally, the potency, dosage, route of administration, onset of action, efficacy and risk of ischemic stroke vary between P2Y12 inhibitors. This study examines the safety and efficacy of clopidogrel compared to ticagrelor in adult patients after neuroendovascular intervention.

Methods: This retrospective study conducted at a comprehensive stroke center assessed patients prescribed either aspirin plus clopidogrel or aspirin plus ticagrelor for neuroendovascular management of ischemic stroke between January 2020 and December 2023. Those patients with a prescription for a P2Y12 inhibitor prior to admission or who were administered tirofiban or eptifibatide within 48 hours of the last drawn PRU level were excluded. The primary outcome was the percentage of patients who achieved goal PRU levels. Secondary outcomes were incidence of recurrent ischemic event, hemorrhage, subsequent neurointervention, adjustments to P2Y12 therapy, and all-cause short-term mortality. Adjustments to P2Y12 therapy included dosage change or transition to other P2Y12 inhibitor.

Results: Therapeutic PRU levels were attained in 109 patients (71.2%) in the clopidogrel group and 73 patients (81.1%) in the ticagrelor group (p = 0.04). No difference was found in recurrent ischemic events (clopidogrel 6.3% vs. ticagrelor 11.1%, p = 0.18). Ticagrelor was associated with a significantly increased rate of hemorrhage (16.7% vs. 4.4%, p < 0.01), and patients on ticagrelor were more likely to require subsequent neurointervention (10% vs. 3.2%; p = 0.02). Significantly more patients in the clopidogrel group required a transition to an alternative P2Y12 inhibitor (18.4% vs. 0%, p < 0.01). Ticagrelor was associated with an increased rate of all-cause short-term mortality (17.8% vs 3.8%, p < 0.01).

Conclusions: Ticagrelor achieved goal platelet inhibition, based on PRU, more often than clopidogrel but was associated with increased rates of bleeding events. This complicates the decision of which P2Y12 to initiate in patients after neuroendovascular intervention.