Angina pectoris and heart attack: What are the advantages or disadvantages of ticagrelor (Brilique)?

Ticagrelor was approved in Germany in late 2010 for use in people with unstable angina pectoris or heart attack. It is taken in addition to acetylsalicylic acid (ASA) and aims to lower the risk for further heart and blood vessel disease.

For whom is ticagrelor an option?

Ticagrelor (trade name Brilique) is an anti-clotting medication aiming to prevent blood clots. Ticagrelor is an option for people with acute coronary syndrome. This disease is usually caused by a blood clot blocking a coronary artery completely or partially. This can lead to problems ranging from severe, but transitory, chest pain (unstable angina pectoris) to severe heart attack. An electrocardiogram (ECG or EKG), which records electrical activity of the heart, can help assess how acute coronary problems have affected the heart. A severe heart attack usually leads to typical changes in a certain part of the ECG graph, called the ST segment. These changes do not occur in unstable angina pectoris. Acute heart symptoms with typical ECG changes are treated differently.

How is ticagrelor used?

• Treatment with ticagrelor should start within 24 hours after unstable angina pectoris or heart attack was diagnosed.
• On the first day, two tablets are to be taken at the same time. Then one tablet should be taken in the morning, and one in the evening, for up to 12 months. The daily dosage is 180 milligrams.
• Ticagrelor is taken in addition to acetylsalicylic acid (ASA, or ASS in German).

What was ticagrelor compared with?

In the summer of 2011, the German Institute for Quality and Efficiency in Health Care (IQWiG) assessed trials that compared ticagrelor with other anti-clotting medications approved for people with acute heart problems with or without typical ECG changes. Examples include clopidogrel and prasugrel.

Does ticagrelor have advantages?

Acute heart problems WITHOUT typical ECG changes:

• Deaths: Ticagrelor has proven advantages for men and women with acute heart problems without typical ECG changes. Out of 1,000 people who took ticagrelor and ASA for 6 to 12 months, 38 people died in the trial. But 53 out of 1,000 people who had the comparator treatment, clopidogrel and ASA, died.
• Heart attacks: In people with acute heart problems without typical ECG changes, ticagrelor was proven to be able to prevent heart attacks better than clopidogrel. Out of 1,000 people who took ticagrelor in addition to ASA for 6 to 12 months, 48 people had a heart attack during this time. But out of 1,000 people who took clopidogrel and ASA, 61 had a heart attack. Data presented to the German Federal Joint Committee (G-BA) are taken into account.

Acute heart problems WITH typical ECG changes:

Only few data are available about people who have a heart attack with typical ECG changes. There is no proof that ticagrelor has advantages over other anti-clotting medications.

Does ticagrelor have disadvantages?

Acute heart problems WITHOUT typical ECG changes:

• Breathing problems: In comparison with clopidogrel, treatment with ticagrelor led to breathlessness (dyspnea) more often. Out of 1,000 people who took ticagrelor for 6 to 12 months, 140 reported breathlessness. Out of 1,000 people who had the comparator treatment clopidogrel, 77 experienced this adverse effect.
• Treatment stopped because of side effects: On the whole, people who took ticagrelor stopped treatment more often than those who took clopidogrel. Out of 1,000 people who took ticagrelor, 82 stopped the treatment because of side effects. Out of 1,000 people who were treated with clopidogrel, 57 stopped treatment.
• Bleeding: Severe bleeding did not occur more often in treatment with ticagrelor than in treatment with clopidogrel.
• Other side effects of ticagrelor and clopidogrel are listed on their respective package inserts.

Acute heart problems WITH typical ECG changes:

• There are only few data on people who have heart attacks with typical ECG changes. There is no proof that ticagrelor is different from other anti-clotting medications in terms of side effects.

Where can I get more information?

This text summarizes the most important results of a review by the German Institute for Quality and Efficiency in Health Care (IQWiG) published in October 2011. Click here (URL: https://www.iqwig.de/a11-02-ticagrelor-nutzenbewertung-gemaess-35a-sgb.986.html?tid=1425&phlex_override_command=element) to read the entire review (in German), and here (URL: https://www.iqwig.de/language-selector.986.en.html?tid=1425&phlex_override_command=element) for the executive summary (in English).

The IQWiG review was commissioned by the German Federal Joint Committee (G-BA) as part of the “benefit assessment  of pharmaceuticals pursuant to § 35a Social Code Book V”. In December 2011, G-BA passed a resolution on the benefit of ticagrelor (Brilique) on the basis of this review and the hearings received. You can find out more about the background of the benefit assessment and the G-BA resolution here (URL: http://www.g-ba.de/informationen/nutzenbewertung/18/#beschluesse)  (in German). To read the G-BA resolution in English, click here (URL: http://www.english.g-ba.de/benefitassessment/resolutions/) .

You can find some useful facts about anti-clotting medication and its safe use in our feature "Anti-clotting medication" (URL: http://www.informedhealthonline.org/index.378.56.en.html) .

To find out more about how to recognize a heart attack read our text "The signs of a heart attack" (URL: http://www.informedhealthonline.org/text-the-signs-of-a-heart-attack.230.en.html) .