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Dyspnea in ticagrelor treated patients in the all-comer randomized GLOBAL LEADERS study and its association with clinical outcomes

Session Poster Session 7

Speaker Mariusz Tomaniak

Event : ESC Congress 2019

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Coronary Artery Disease: Pharmacotherapy
  • Session type : Poster Session

Authors : M Tomaniak (Warsaw,PL), P Chichareon (Amsterdam,NL), R Modolo (Amsterdam,NL), S Plante (Newmarket,CA), P Brunel (Paris,FR), F Beygui (Caen,FR), R-J Van Geuns (Nijmegen,NL), R Storey (Sheffield,GB), C Hamm (Giessen,DE), PG Steg (Paris,FR), P Vranckx (Hasselt,BE), S Windecker (Bern,CH), Y Onuma (Rotterdam,NL), M Valgimigli (Bern,CH), PW Serruys (London,GB)

M Tomaniak1 , P Chichareon2 , R Modolo2 , S Plante3 , P Brunel4 , F Beygui5 , R-J Van Geuns6 , R Storey7 , C Hamm8 , PG Steg9 , P Vranckx10 , S Windecker11 , Y Onuma12 , M Valgimigli11 , PW Serruys13 , 1Erasmus Medical Centre, Rotterdam, Medical University of Warsaw - Warsaw - Poland , 2Academic Medical Center - Amsterdam - Netherlands (The) , 3Southlake Regional Health Centre - Newmarket - Canada , 4Clinique de Fontaine - Paris - France , 5CHU de Caen - Caen - France , 6Erasmus Medical Centre, Rotterdam, Radboud UMC - Nijmegen - Netherlands (The) , 7University of Sheffield - Sheffield - United Kingdom of Great Britain & Northern Ireland , 8University of Giessen - Giessen - Germany , 9FACT (French Alliance for Cardiovascular Trials), Université Paris Diderot, Hôpital Bichat - Paris - France , 10Hartcentrum Hasselt, Jessa Ziekenhuis - Hasselt - Belgium , 11Bern University Hospital, Inselspital, University of Bern - Bern - Switzerland , 12Erasmus Medical Centre, ThoraxCenter - Rotterdam - Netherlands (The) , 13NHLI, Imperial College London - London - United Kingdom of Great Britain & Northern Ireland ,

On behalf: GLOBAL LEADERS Study Investigators


Dyspnea represents a drug adverse effect reported with a higher frequency for ticagrelor, as compared with other P2Y12 antagonists. The impact of dyspnea on clinical outcomes has not been yet evaluated in the context of aspirin-free therapies after percutaneous coronary intervention (PCI). 

The study aimed to evaluate the incidence of dyspnea and its associations with demographic characteristics and clinical outcomes in patients undergoing PCI treated with ticagrelor either as monotherapy or as a part of a dual antiplatelet therapy (DAPT) in the GLOBAL LEADERS cohort. 

This is a sub-analysis of the randomized all-comer GLOBAL LEADERS study (n=15991), comparing the experimental strategy of ticagrelor monotherapy following one-month DAPT after PCI with the reference strategy of 12-month DAPT followed by 12-month aspirin monotherapy. The incidence of dyspnea reported as adverse event (AE) and its relation to demographic characteristics and 2-year clinical outcomes was evaluated (intention-to-treat analysis). Multivariable Cox proportional hazards models were performed, including randomized treatment and incidence of first dyspnea event as a time-dependent covariate. The primary endpoint was a composite of 2-year all-cause mortality or centrally adjudicated, new Q-wave myocardial infarction (MI). Patient-oriented clinical endpoints (POCE) comprised all-cause death, any stroke, MI or revascularization, whereas net adverse clinical events (NACE) included POCE and Bleeding Academic Research Consortium (BARC)-defined bleeding type 3 or 5. 

Overall, dyspnea was reported as an AE in 2101 patients (13.2%) up to two years of follow-up, with a higher frequency in the experimental arm (16.4%) as compared with the reference group (11.1%) (hazard ratio [HR]1.70, 95% confidence interval [CI] 1.56-1.86, p=0.001).
Predictors of dyspnea AE up to 2 years by multivariate analyses were: chronic obstructive pulmonary disease (HR1.71, 95%CI 1.56–1.87, p=0.001), female gender (HR1.31, 95%CI 1.18–1.44, p=0.001), hypertension (HR1.31, 95%CI 1.19-1.44, p=0.001, prior coronary artery bypass grafting (HR1.30, 95%CI 1.10–1.54, p=0.003), left ventricle ejection fraction below 40% (HR1.22, 95%CI 1.04-1.42, p=0.012), presentation with acute coronary syndrome (HR1.19, 95%CI 1.09-1.29, p=0.001) and body mass index (=27kg/m2) (HR1.17, 95%CI 1.08–1.28, p=0.001).
In patients who reported dyspnea AE, the two-year rates of the efficacy and safety endpoints in the experimental and reference arm were: for the primary endpoint 3.4% vs. 4.3% (p adjusted=0.807), for POCE 15.8% vs. 17.6% (p adjusted=0.218), for NACE 17.2% vs. 19.6% (p adjusted=0.082), for BARC 3 or 5 type bleeding 17.2% vs. 19.6% (p adjusted=0.082), respectively. 

The occurrence of dyspnea AE up to two years after PCI appeared not to affect the safety of the experimental treatment strategy of 23-month ticagrelor monotherapy following one-month DAPT after PCI.

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