In patients aged ≥70 years with non-ST-elevation acute coronary syndrome (NSTE-ACS), clopidogrel is associated with fewer bleeding events compared with ticagrelor but similar net clinical benefits (in terms of all-cause death, myocardial infarction, stroke and bleeding). This finding indicates that clopidogrel can be used as a first choice therapy for older patients who are at increased risk of bleeding.

Current guidelines recommend the use of ticagrelor or prasugrel over clopidogrel to prevent recurrent thrombotic events in patients with NSTE-ACS. However, bleeding risk increases with age, and ticagrelor has been associated with more frequent bleeding events than clopidogrel among older patients. To confirm these findings, investigators of the POPular AGE randomized trial sought to assess the bleeding risks of antiplatelet therapy in older patients with NSTE-ACS.

In total, 1,002 patients aged ≥70 years with NSTE-ACS were randomly assigned to receive clopidogrel (n = 500) or either ticagrelor or prasugrel (n = 502; referred to as ticagrelor group because the majority of the patients received ticagrelor). At 12 months, the primary bleeding outcome (composite of PLATO major or minor bleeding) occurred less frequently in the clopidogrel group than in the ticagrelor group (18% versus 24%, HR 0.71, 95% CI 0.54–0.94, P = 0.02). However, the net clinical benefit outcome was similar between the two groups (28% versus 32%).

In summary, clopidogrel is associated with reduced bleeding risks compared with ticagrelor in patients aged ≥70 years with NSTE-ACS. “Personalized antiplatelet therapy by means of platelet function testing or genotyping might further optimize antiplatelet therapy in older patients,” comment the investigators.