Background: Patients with chronic obstructive pulmonary disease (COPD) experiencing acute coronary syndromes (ACS) are at
high risk for clinical events. In the Platelet Inhibition and Patient Outcomes (PLATO) trial, ticagrelor versus clopidogrel reduced the
primary endpoint of death from vascular causes, myocardial infarction, or stroke after ACS, but increased the incidence of dyspnea,
which may lead clinicians to withhold ticagrelor from COPD patients.
Methods and Results: In 18 624 patients with ACS randomized to treatment with ticagrelor or clopidogrel, history of COPD was
recorded in 1085 (5.8%). At 1 year, the primary endpoint occurred in 17.7% of patients with COPD versus 10.4% in those without
COPD (P<0.001). The 1-year event rate for the primary endpoint in COPD patients treated with ticagrelor versus clopidogrel was
14.8% versus 20.6% (hazard ratio [HR]=0.72; 95% confidence interval [CI]: 0.54 to 0.97), for death from any cause 8.4% versus
12.4% (HR=0.70; 95% CI: 0.47 to 1.04), and for PLATO-defined major bleeding rates at 1 year 14.6% versus 16.6% (HR=0.85; 95%
CI: 0.61 to 1.17). Dyspnea occurred more frequently with ticagrelor (26.1% vs. 16.3%; HR=1.71; 95% CI: 1.28 to 2.30). There was
no differential increase in the relative risk of dyspnea compared to non-COPD patients (HR=1.85). No COPD status-by-treatment
interactions were found, showing consistency with the main trial results.
Conclusions: In this post-hoc analysis, COPD patients experienced high rates of ischemic events. Ticagrelor versus clopidogrel
reduced and substantially decreased the absolute risk of ischemic events (5.8%) in COPD patients, without increasing overall major
bleeding events. The benefit-risk profile supports the use of ticagrelor in patients with ACS and concomitant COPD.