Ticagrelor versus clopidogrel after fibrinolysis in STEMI: real-world analysis on reperfusion success

In regions where timely primary percutaneous coronary intervention (PCI) is not possible, fibrinolysis remains an important therapy for patients with ST-elevation myocardial infarction (STEMI). Although current guidelines recommend clopidogrel during fibrinolysis, many patients referred to tertiary centres have already received ticagrelor in pre-hospital or emergency settings. The implications of this practice regarding reperfusion efficacy and TIMI flow restoration are still uncertain.

This study aimed to explore whether ticagrelor could offer enhanced reperfusion or angiographic outcomes in real-world practice.

A retrospective analysis was conducted on 154 consecutive STEMI patients who received fibrinolysis and were transferred to our center for facilitated or rescue PCI between 2020 and 2023. Patients were divided into two groups based on antiplatelet therapy: Group 1 with clopidogrel and Group 2 with ticagrelor. Reperfusion was assessed clinically by the degree of ST-segment resolution and symptom relief, and angiographically including pre-intervention Thrombolysis in Myocardial Infarction (TIMI) flow grade ≥2, final TIMI flow grade 3, and improvement in flow grade. Comparisons between groups were made using Chi-square and Fisher’s exact tests.

A total of 154 patients were included, 78 treated with clopidogrel and 76 with ticagrelor. No statistically significant differences were found between groups. Clinical evidence of reperfusion on arrival was observed in 65% of patients, of whom 62% had received ticagrelor. Pre-intervention TIMI flow grade ≥2 was present in 66.7% of the clopidogrel group and 69.7% of the ticagrelor group (p = 0.73). Final TIMI flow grade 3 was achieved in 91.0% and 93.4%, respectively (p = 0.77). Improvement in flow grade occurred in 53.8% and 48.7% of patients, respectively (p = 0.63).

Although ticagrelor-treated patients showed a numerically higher proportion of clinical reperfusion and final TIMI 3 flow, these differences were not statistically significant. The high success rate of fibrinolysis overall (clinical reperfusion in two-thirds of patients and angiographic TIMI 3 in >90%) highlights the effectiveness of fibrinolysis in real-world settings.

In STEMI patients undergoing fibrinolysis followed by coronary angiography, ticagrelor was associated with similar rates of clinical and angiographic reperfusion compared to clopidogrel.