Abstract

Background: Although cancer is one of the major high bleeding risk criteria, patients with cancer undergoing percutaneous coronary intervention (PCI) experience a heightened risk of both ischemic and bleeding events. Hypothesis: Potent P2Y12 inhibitors (P2Y12i; prasugrel and ticagrelor), as compared to clopidogrel, might reduce the risk of thrombotic complications in patients with cancer undergoing PCI. Aims: To evaluate the safety and efficacy of potent P2Y12 inhibitors, compared to clopidogrel, in cancer patients undergoing PCI. Methods: Consecutive cancer patients undergoing PCI at a tertiary center between 2012 and 2022 who were discharged on potent P2Y12i were compared with those on clopidogrel. Patients on chronic anticoagulant therapy were excluded. The primary composite efficacy endpoint was major adverse cardiac and cerebrovascular events (MACCE), including death, myocardial infarction or stroke, while bleeding was the key safety endpoint. Results: Of the 1,702 patients included in the study, 373 (21.9%) were treated with potent P2Y12i and 1,329 (78.1%) with clopidogrel. The prevalence of P2Y12i use was 12.3% in patients with active cancer and 23.1% in those with cancer in remission. Factors associated with potent P2Y12i use were acute coronary syndrome presentation and lesion length, while clopidogrel at discharge was associated with active cancer status, thrombocytopenia, older age and femoral access. MACCE at 1 year occurred in 3.5% of patients in the potent P2Y12i group vs. 6.8% in the clopidogrel group (p=0.038; adj. HR: 0.53, 95% CI: 0.26-1.10), while no differences in terms of bleeding were detected (5.5 vs. 7%, adj. HR: 0.92, 95% CI: 0.53 - 1.60). At subgroup analysis, the reduction in MACCE was significant in patients with remission but not active cancer (p for interaction = 0.011). Conclusions: Potent P2Y12i appear to be safe in terms of bleeding and potentially associated with greater ischemic risk reduction compared to clopidogrel among patients with cancer undergoing PCI, particularly in case of cancer in remission.