Ticagrelor after pharmacological thrombolysis in patients with ST-segment elevation myocardial infarctions: insight from a trial sequential analysis

  • Mohammed OsmanEmail author
  • Babikir Kheiri
  • Amanda Jo Shigle
  • Maryam Saleem
  • Khansa Osman
  • Partho P. Sengupta
  • Jason A. Moreland


Few randomized controlled trials (RCTs) have compared ticagrelor to clopidogrel after thrombolytic therapy in patients with ST-segment elevation myocardial infarction (STEMI). To assess the quality of the current evidence, a trial sequential analysis (TSA) of all the available RCTs was performed. A literature search through electronic databases for relevant RCTs was completed. Trial sequential boundaries were applied to the meta-analysis to guard against statistical error, calculate the information size (IS), and assess the quality of the currently available evidence. The safety outcome was bleeding at 30-days and the efficacy outcome was major adverse cardiovascular events at 30-days. There were 3 RCTs with a total of 3999 patients were included. For the safety and efficacy outcomes, there was no difference between the ticagrelor and clopidogrel groups (RR 0.94; 95% CI 0.56–1.60, p = 0.83) and (RR 0.87; 95% CI 0.49–1.52, p = 0.62), respectively. The corresponding TSA revealed an IS of 20,928 and 37,266 for safety and efficacy outcomes, respectively. The Z-curves for both outcomes failed to cross the conventional boundary of significance and TSA boundary, indicating no statistical difference between the ticagrelor and clopidogrel group and lack of firm evidence from the currently available RCTs to draw conclusion. Based on the current available RCTs, there is not enough evidence to support or refute better outcomes with ticagrelor in patients with STEMI treated with thrombolytics. Larger RCTs with enough power are needed before firm recommendations can be applied.


Acute coronary syndrome St-segment elevation myocardial infarction Ticagrelor Clopidogrel Thrombolytics 


Compliance with ethical standards

Conflict of interest

All the authors declare that they have no conflict of interest.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Mohammed Osman
    • 1
    Email author
  • Babikir Kheiri
    • 2
  • Amanda Jo Shigle
    • 1
  • Maryam Saleem
    • 1
  • Khansa Osman
    • 3
  • Partho P. Sengupta
    • 1
  • Jason A. Moreland
    • 1
  1. 1.Division of CardiologyWest Virginia University School of MedicineMorgantownUSA
  2. 2.Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandUSA
  3. 3.Michigan State UniversityFlintUSA

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