BACKGROUND: Whether ticagrelor in chronic coronary syndrome patients undergoing complex percutaneous coronary intervention (PCI) can prevent cardiovascular events is unknown. OBJECTIVES: The authors sought to evaluate outcomes of complex PCI and the efficacy of ticagrelor vs clopidogrel in stable patients randomized in the ALPHEUS (Assessment of Loading with the P2Y12 inhibitor ticagrelor or clopidogrel to Halt ischemic Events in patients Undergoing elective coronary Stenting) trial. METHODS: All PCI procedures were blindly reviewed and classified as complex if they had at least 1 of the following criteria: stent length >60 mm, 2-stent bifurcation, left main, bypass graft, chronic total occlusion, use of atherectomy or guiding catheter extensions, multiwire technique, multiple stents. The primary endpoint was a composite of type 4a or b myocardial infarction (MI) and major myocardial injury during the 48 hours after PCI. We compared the event rates according to the presence or not of complex PCI criteria and evaluated the interaction with ticagrelor or clopidogrel. RESULTS: Among the 1,866 patients randomized, 910 PCI (48.3%) were classified as complex PCI. The primary endpoint was more frequent in complex PCI (45.6% vs 26.6%; P < 0.001) driven by higher rates of type 4 MI and angiographic complications (12.2% vs 4.8 %; P < 0.001 and 19.3% vs 8.6%; P < 0.05, respectively). The composite of death, MI, and stroke at 48 hours (12.7% vs 5.1 %; P < 0.05) and at 30 days (13.4% vs 5.3%; P < 0.05) was more frequent in complex PCI. No interaction was found between PCI complexity and the randomized treatment for the primary endpoint (Pinteraction = 0.47) nor the secondary endpoints. CONCLUSIONS: In chronic coronary syndrome, patients undergoing a complex PCI have higher rates of periprocedural and cardiovascular events that are not reduced by ticagrelor as compared with clopidogrel.

ACTION Study Group Unité de Recherche Clinique Hôpital Fernand Widal EA 4543 Université Paris 1 Panthéon Sorbonne Paris Paris France

Cardiocenter 3rd Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady Prague Czech Republic

Cardiology Department Caen University Hospital ACTION Study Group Caen France

Cardiology Department Centre Cardiologique du Nord Paris France

Cardiology Department Chartres Hospital Chartres France

Cardiology Department General Hospital Yves Le Foll Saint Brieuc France

Cardiology Department Nîmes University Hospital Montpellier University ACTION Study Group Nîmes France

Cardiology Department Université de Paris Hôpital Bichat AP HP French Alliance for Cardiovascular Trials INSERM U1148 Paris France

Département de Cardiologie Grand Hôpital de l'Est Francilien site Marne La Vallée Marne la Vallée France

Department of Cardiology Arnaud de Villeneuve Hospital Montpellier University Montpellier France

Department of Cardiology Cochin Hospital Hôpitaux Universitaire Paris Centre Assistance Publique des Hôpitaux de Paris Paris France

Department of Cardiology European Hospital Georges Pompidou Assistance Publique Hôpitaux de Paris Paris Cité University Sudden Cardiac Death Expert Center INSERM U 971 PARCC Paris France

Division of Cardiovascular Medicine Nouvel Hôpital Civil Strasbourg University Hospital Strasbourg France

Les Grands Prés Cardiac Rehabilitation Centre Villeneuve St Denis France

Sorbonne Université ACTION Study Group INSERM UMRS1166 Hôpital Pitié Salpêtrière Paris France

Sorbonne Université ACTION Study Group INSERM UMRS1166 Hôpital Pitié Salpêtrière Paris France; Cardiology Department Nîmes University Hospital Montpellier University ACTION Study Group Nîmes France

University Hospital Brno Medical Faculty of Masaryk University Brno Brno Czech Republic

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