Potent P2Y12 inhibitors versus clopidogrel in cancer patients undergoing percutaneous coronary intervention.

Background: Patients with cancer undergoing percutaneous coronary intervention (PCI) experience higher risk of both ischemic and bleeding events. The aim of this study is to assess ischemic and bleeding risks after PCI in cancer patients treated with potent P2Y12 inhibitors (P2Y12i; prasugrel and ticagrelor), compared to clopidogrel.

Methods: Consecutive cancer patients undergoing PCI at a tertiary centre between 2012 and 2022 and discharged on P2Y12i were included. Propensity score covariate adjustment was used to account for baseline differences between patients treated with potent P2Y12i and clopidogrel. Key clinical endpoints included major adverse cardiac and cerebrovascular events (MACCE - composite of death, myocardial infarction or stroke) and major bleeding.

Results: Of the 1,702 included patients, 373 (21.9%) were treated with potent P2Y12i and 1,329 (78.1%) with clopidogrel. Factors associated with potent P2Y12i use were acute coronary syndrome presentation and lesion length, while clopidogrel use was associated with active cancer status, thrombocytopenia, older age and femoral access. MACCE at one year occurred in 3.5% of patients treated with potent P2Y12i vs. 6.8% of those receiving clopidogrel (log-rank p=0.035; adj. HR: 0.53, 95% CI: 0.26-1.10), while no differences in bleeding risk were detected (5.5% vs. 7.0%, adj. HR: 0.92, 95% CI: 0.53 - 1.60). The reduction in MACCE was significant in patients with remission but not active cancer (p-interaction = 0.011).

Conclusions: Among cancer patients undergoing PCI, potent P2Y12i were associated with similar bleeding risk and lower incidence of ischemic events compared to clopidogrel, however with no significant difference after propensity score adjustment.