INTERVIEW
Ticagrelor as Long-term
Secondary Prevention
in Patients with PAD and
Prior MI
An Interview with Marc P. Bonaca, MD
Investigators for two separate sub-analyses
of PEGASUS-TIMI 54 presented their results at
ACC.16 in Chicago, IL, looking specifically at
the long-term use of ticagrelor in patients with a
history of myocardial infarction (MI) and at least
one additional risk factor for thrombotic cardiovascular events. The first sub-analysis included
patients with peripheral artery disease (PAD), and
the second looked at patients with diabetes. Marc
Bonaca, MD, of Brigham and Women’s Hospital in
Boston, MA, is lead investigator for the PAD subanalysis of PEGASUS.
CSWN: Why did you focus on this population of patients with PAD?
Marc P. Bonaca, MD: We know that patients
with PAD are at a heightened ischemic risk, as
well as for MI, stroke and cardiovascular death.
We also know that patients with prior MI and
PAD (so-called “polyvascular” disease) are at even
higher risk. So this is a very high-risk population.
The PEGASUS-TIMI 54 study overall showed
that ticagrelor reduced cardiovascular risk over
the long term. There was some increased bleeding. We felt this was a cohort that might derive
particularly robust benefit from more intensive
anti-thrombotic strategy as long-term secondary
prevention.
How many patients were analyzed?
Just over 1,000 patients were in the PAD subgroup. They were analyzed as the primary group
for this study. All the patients were randomized
1 to th3 years after MI. These 1,100 patients or
so had symptomatic PAD or abnormal anklebrachial index, and they were followed for 3 years
of therapy.
What did you find?
First, we found that when you look at patients
that have PAD and prior MI versus patients
with prior MI alone, those that have PAD are
much higher risk of major adve rse cardiovascu-
30 CardioSource WorldNews
Marc Bonaca, MD
lar events. The event rate at 3 years was 20%,
meaning one in five patients had CV death, MI,
or stroke, versus a much lower rate of patients
without PAD. And when you look at the individual events, they’re at higher risk of cardiovascular
death, all-cause mortality, and of course limb
events. We saw that it was a much higher-risk
population than those without PAD, and also that
that relationship remained even after we adjusted
for all of the imbalances at baseline, so that they
have more diabetes, more smoking, etc. Even after
you adjust for that, they’re at higher risk.
Is that appreciated among the cardiovascular
community?
Yes. I think that people understand that patients
with PAD are at higher risk for ischemic events,
not necessarily beyond prior MI. And so I think
this does add to the fact that polyvascular disease, as others have described, is a much higher-
We felt this was a
cohort that might
derive particularly
robust benefit from
more intensive antithrombotic strategy as
long-term secondary
prevention.
July 2016