Switching from ticagrelor to clopidogrel at one month after MI: benefit under 75, uncertain above

Design

Prespecified secondary analysis of a randomised trial

Population

2697 patients event-free 1 month after PCI for acute MI

Primary outcome

Net clinical events (CV death, MI, stroke, BARC 2/3/5 bleeding) at 1 year

Effect

Under 75: 4.1% vs 7.2%, aHR 0.54 (0.38–0.77); ≥75: aHR 0.54 (0.25–1.17)

TALOS-AMI randomised patients who were event-free one month after PCI for myocardial infarction, while taking aspirin and ticagrelor, to switch to aspirin and clopidogrel or to continue ticagrelor. This prespecified secondary analysis of 2697 participants examined whether the effect differed by age.

In patients under 75 (n = 2376), de-escalation reduced the net clinical endpoint of cardiovascular death, MI, stroke and clinically relevant bleeding at one year (4.1% vs 7.2%; aHR 0.54, 95% CI 0.38–0.77), driven largely by less bleeding (2.8% vs 4.9%). In those 75 and over, the point estimates were similar (6.4% vs 11.6%; aHR 0.54, 0.25–1.17) but the interval was wide. Tests for interaction showed no difference by age, and most bleeding in older patients occurred within the first six months.

The trial was conducted in Korea, where clopidogrel responsiveness and bleeding risk differ from Western populations, and ticagrelor-to-clopidogrel switching is already common in Indian practice for cost. This analysis supports an unguided switch at one month in stable patients under 75. For older patients it does not show harm, but it is too small to show benefit.

• In patients under 75 who are event-free a month after PCI for MI, consider stepping down from ticagrelor to clopidogrel.
• Before switching, confirm there has been no recurrent ischaemia, stent thrombosis or major bleeding in the first month.
• In patients 75 and over, the trial is underpowered; decide on bleeding and ischaemic risk individually.
• Bleeding risk in older patients concentrated in the first six months, so review early.

Why it matters

Cost and bleeding often force this switch anyway; this gives it a randomised evidence base in patients under 75.

Don't overread it

The 75-and-over result is a subgroup with a confidence interval crossing 1.0; it neither confirms nor excludes benefit.

The statistics, in plain English

An adjusted hazard ratio of 0.54 means about half the rate of net events. In the older group the interval runs from 0.25 to 1.17, so the true effect could be large benefit or slight harm. A non-significant interaction test means there is no evidence that age changes the effect, which is not the same as proof that it does not.

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