Introduction: Acute coronary syndrome (ACS) can be defined as any group of clinical symptoms consistent with acute myocardial ischemia. This may include unstable angina (UA), non—ST-segment elevation and ST-segment elevation myocardial infarction. Antiplatelet therapy is an essential part of management of patients with acute coronary syndrome and may consist of aspirin (irreversibly inhibiting cyclooxygenase 1), clopidogrel (P2Y12 adenosine diphosphate receptor blocker), newer P2Y12 ADP Inhibitors (Prasugrel & Ticagrelor) and GP IIb/IIIa Inhibitors. There are studies which have reported that there is increased risk of dyspnea in patients of acute coronary syndrome who have been on Ticagrelor (The Platelet Inhibition and Patient Outcomes (PLATO) trial) due to which Ticagrelor was being avoided in patients who had history of COPD. We conducted this comparative study to compare effects of Ticagrelor and clopidogrel on pulmonary functions of patients with CAD.

Materials and Methods: This was a comparative study which a total 120 patients with acute coronary syndrome were enrolled depending upon a predefined inclusion and exclusion criteria. The study was conducted in the department of medicine in a tertiary care medical college. A detailed clinical history was taken and through clinical examination was done in all the cases. Demographic details were noted in all the cases. Out of these total 120 patients 60 patients each were randomized to ticagrelor (90 mg twice daily) (Group A) and clopidogrel (75 mg once daily) (Group B). After a continuous therapy of 1-month pulmonary function tests (Pulse oximetry (SpO2), spirometry FEV1, FVC, FEF25-75) were repeated. Pulmonary function tests in Group A and Group B were compared. For statistical purposes P value less than 0.05 was taken as statistically significant.

Results:  Out of 120 patients there were 80 (66.67%) males and 40 (33.33%) females with a M:F ratio of 1:0.5. The gender difference in both the groups was statistically not significant (P>0.05). The mean age of the patients in group A and group B was found to be 61.56 +/- 3.98 and 62.41 +/- 3.40   respectively. Hypertension, dyslipidemia and diabetes mellitus were the most common co-morbid conditions in patients with CAD. Mean FEV1 values, FEV1/FVC ratio, FEF25-75 % and SPO2 levels were found to be comparable in both the groups with no statistically significant difference.

Conclusion:  Ticagrelor does not appear to be any adverse effect on pulmonary function tests as compared to clopidogrel in patients with CAD and hence appears to be preferable as compared to clopidogrel due to considerable reduction in cardiovascular death, myocardial infarction and stroke.

Keywords: Coronary Artery Disease, Ticagrelor, Clopidogrel, Pulmonary Function Test.

1. Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc. 2009;84(10):917–938.
2. Chaturvedula S, Diver D, Vashist A. Antiplatelet Therapy in Coronary Artery Disease: A Daunting Dilemma. J Clin Med. 2018 Apr 9;7(4). pii: E74.
3. Falk JA, Kadiev S, Criner GJ, Scharf SM, Minai OA, Diaz P. Cardiac disease in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5(4):543–548.
4. Boschetto P, Beghé B, Fabbri LM, Ceconi C. Link between chronic obstructive pulmonary disease and coronary artery disease: implication for clinical practice. Respirology. 2012 Apr;17(3):422-31.
5. Cazzola M, Calzetta L, Matera MG, Muscoli S, Rogliani P, Romeo F. Chronic obstructive pulmonary disease and coronary disease: COPDCoRi, a simple and effective algorithm for predicting the risk of coronary artery disease in COPD patients. Respir Med. 2015 Aug;109(8): 1019-25.
6. Lee CW. Dual antiplatelet therapy for coronary artery disease. Circ J. 2015; 79(2):255-62.

7. Gurbel PA, Myat A, Kubica J, Tantry US. State of the art: Oral antiplatelet therapy. JRSM Cardiovasc Dis. 2016;5: 2048004016652514. Published 2016 Jun 1.
8. James S, Budaj A, Aylward P, Buck KK, Cannon CP, Cornel JH, Harrington RA, Horrow J, Katus H, Keltai M, Lewis BS, Parikh K, Storey RF, Szummer K, Wojdyla D, Wallentin L. Ticagrelor versus clopidogrel in acute coronary syndromes in relation to renal function: results from the Platelet Inhibition and Patient Outcomes (PLATO) trial. Circulation. 2010 Sep 14;122(11):1056-67.
9. James S, Akerblom A, Cannon CP, Emanuelsson H, Husted S, Katus H, Skene A, Steg PG, Storey RF, Harrington R, Becker R, Wallentin L. Comparison of Ticagrelor, the first reversible oral P2Y(12) receptor antagonist, with clopidogrel in patients with acute coronary syndromes: Rationale, design, and baseline characteristics of the PLATelet inhibition and patient Outcomes (PLATO) trial. Am Heart J. 2009 Apr;157(4):599-605.
10. Nicolau JC, Baracioli LM, Giugliano RP. Ticagrelor for the prevention of ischemic events in patients with prior myocardial infarction and peripheral artery disease. Expert Opin Pharmacother. 2018 Jun;19(9):1013-1019.
11. Jamee A, Abed Y, Jalambo MO. Gender difference and characteristics attributed to coronary artery disease in Gaza-Palestine. Glob J Health Sci. 2013;5(5): 51–56. Published 2013 May 26.
12. Folsom AR, Arnett DK, Hutchinson RG, Liao F, Clegg LX, Cooper LS. Physical activity and incidence of coronary heart disease in middle-aged women and men. Med Sci Sports Exerc. 1997 Jul;29(7):901-9.
13. McCarter RV, McKay GJ, Quinn NB, Chakravarthy U, MacGillivray TJ, Robertson G,Pellegrini E, Trucco E, Williams MC, Peto T, Dhillon B, van Beek EJ, Newby DE,Kee F, Young IS, Hogg RE. Evaluation of coronary artery disease as a risk factor for reticular pseudodrusen. Br J Ophthalmol. 2018 Apr;102(4):483-489.
14. Wang C, Zhao P, Luo P, Liu W, Wang H, Zhao Q. Prevalence and risk factors ofcoronary artery disease in patients with chronic viral hepatitis. Postgrad Med.2015;127(8):786-90.
15. Banasiak W, Pociupany R, Wilkins A, Ponikowski P. Characteristics of patients with coronary artery disease managed on an outpatient basis in the population of  Results of the multicentre RECENT trial. Kardiol Pol. 2007 Feb;65(2):132-40; discussion 141-2.
16. Soubassi LP, Papadakis ED, Theodoropoulos IK, Poulos GD, Chaniotis D, Tsapakidis IP, Zerefos SN, Douli M, Chiras TCh, Kouvelis A, Daglas GK, Soubassi SP, Valis DN, Zerefos NS. Incidence and risk factors of coronary artery disease in patients on chronic hemodialysis. Int J Artif Organs. 2007 Mar;30(3):253-7.
17. Brochu M, Poehlman ET, Savage P, Ross S, Ades PA. Coronary risk profiles inmen with coronary artery disease: effects of body composition, fat distribution, age and fitness. Coron Artery Dis. 2000 Mar;11(2):137-44.
18. Storey RF, Becker RC, Harrington RA, Husted S, James SK, Cools F, Steg PG, Khurmi NS, Emanuelsson H, Lim ST, Cannon CP, Katus HA, Wallentin L. Pulmonary function in patients with acute coronary syndrome treated with ticagrelor or clopidogrel (from the Platelet Inhibition and Patient Outcomes [PLATO] pulmonary function substudy). Am J Cardiol. 2011 Dec 1;108(11):1542-6.
19. Butler K, Maya J, Teng R. Effect of ticagrelor on pulmonary function inhealthy elderly volunteers and asthma or chronic obstructive pulmonary diseasepatients. Curr Med Res Opin. 2013 May;29(5):569-77.
20. Andell P, James SK, Cannon CP, et al. Ticagrelor Versus Clopidogrel in Patients With Acute Coronary Syndromes and Chronic Obstructive Pulmonary Disease: An Analysis From the Platelet Inhibition and Patient Outcomes (PLATO) Trial. J Am Heart Assoc. 2015;4(10):e002490. Published 2015 Oct 9.

Abhinav Chhabra

Resident, DM Cardiology, Department of Cardiology, MGM Medical College & Hospital, Aurangabad, Maharashtra (431003), India