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BRILINTA (Ticagrelor) Receives Additional Class I Recommendation in Updated ACCF/AHA Guidelines for the Management of STEMI Patients
[December 17, 2012]

BRILINTA (Ticagrelor) Receives Additional Class I Recommendation in Updated ACCF/AHA Guidelines for the Management of STEMI Patients

WILMINGTON, Del. --(Business Wire)--

AstraZeneca (NYSE: AZN) announced today that a combined panel of experts from the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) have updated their guidelines to include a Class I recommendation for use of the oral antiplatelet (OAP) medicine BRILINTA® (ticagrelor) tablets in patients with ST-elevation myocardial infarction (STEMI) managed invasively.1 With this latest guidelines update, BRILINTA is included in more than 10 major acute coronary syndrome (ACS (News - Alert)) treatment guidelines globally.1-11

"The U.S. Cardiology community is again acknowledging the clinical value of BRILINTA," said James Ferguson, MD, Executive Director, Medical Affairs and Strategic Development, US, and Vice President for Global Medical Affairs. "This significant milestone, along with the inclusion in the NSTEMI Guidelines in July, solidifies the position of BRILINTA in multiple ACS guidelines as an important part of standard of care for both STEMI and NSTEMI patients."2

A Class I recommendation is the highest recommendation provided by the guidelines committee.

Following are specific Class I and Class IIa recommendations within the guidelines relating to OAPs, including BRILINTA, as well as the use of aspirin (the recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily):

Antiplatelet Therapy to Support Primary Percutaneous Coronary Intervention (PCI (News - Alert)) for STEMI: Recommendations


Class I

1. Aspirin 162 to 325 mg should be given before primary PCI. (Level of Evidence (LOE): B)


2. After PCI, aspirin should be continued indefinitely. (LOE: A)


3. A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at time of primary PCI to patients with STEMI. Options include:

a. Clopidogrel 600 mg (LOE: B); or

b. Prasugrel 60 mg (LOE: B); or

c. Ticagrelor 180 mg (LOE: B)


4. P2Y12 inhibitor therapy should be given for 1 year to patients with STEMI who receive a stent (bare-metal stent [BMS] or drug-eluting stent [DES]) during primary PCI using the following maintenance doses:

a. Clopidogrel 75 mg daily (LOE: B); or

b. Prasugrel 10 mg daily (LOE: B); or

c. Ticagrelor 90 mg twice a day (LOE: B)


Class IIa

1. It is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses after primary PCI. (LOE: B)


2. It is reasonable to begin treatment with an intravenous GP IIb/IIIa receptor antagonist such as abciximab (LOE: A), high-bolus-dose tirofiban (LOE: B), or double-bolus eptifibatide (LOE: B) at the time of primary PCI (with or without stenting or clopidogrel pre-treatment) in selected patients with STEMI who are receiving unfractionated heparin (UFH).


BRILINTA Indication

BRILINTA is indicated to reduce the rate of thrombotic cardiovascular (CV) events in patients with acute coronary syndrome (ACS: unstable angina [UA], non-ST-elevation myocardial infarction [NSTEMI], or ST-elevation myocardial infarction [STEMI]). BRILINTA has been shown to reduce the rate of a combined end point of CV death, myocardial infarction (MI), or stroke compared to clopidogrel. The difference between treatments was driven by CV death and MI with no difference in stroke. In patients treated with an artery-opening procedure known as percutaneous coronary intervention (PCI), BRILINTA reduces the rate of stent thrombosis.

BRILINTA has been studied in ACS in combination with aspirin. Maintenance doses of aspirin above 100 mg decreased the effectiveness of BRILINTA. Avoid maintenance doses of aspirin above 100 mg daily.

Since receiving FDA approval in July 2011, BRILINTA has now been added to six established treatment guidelines in the US. In July 2012, a combined panel of experts from the ACCF and AHA updated their guidelines to include a Class I recommendation for the use of BRILINTA in patients with Unstable Angina (UA) or NSTEMI, managed both invasively or non-invasively.2

In February 2012, the American College of Chest Physicians (ACCP) updated its guidelines for Antithrombotic Therapy to include a recommendation for administering BRILINTA with low-dose aspirin to patients in the first year after ACS who have not undergone PCI or who have undergone PCI with stent placement. This was the first time that clinical treatment guidelines in the US specifically suggested use of BRILINTA over clopidogrel, as a grade 2B recommendation.3

In November 2011, a combined expert committee from ACCF, AHA and the Society for Cardiovascular Angiography and Interventions (SCAI) updated its guidelines for the management of patients undergoing PCI to provide a Class I recommendation for giving BRILINTA to patients with ACS undergoing PCI with stenting.4 Additionally, AHA/ACCF also revised their Guidelines on Secondary Prevention and Risk Reduction Therapy to include BRILINTA, in combination with low-dose aspirin, as a Class I therapy to be taken twice daily for at least 12 months in patients receiving a bare-metal stent (BMS) or drug-eluting stent (DES) during PCI for ACS.5

The ACCF/AHA guidelines for CABG, released in November 2011, include a Class I recommendation that BRILINTA should be discontinued for at least 5 days before surgery, in patients referred for elective CAGB.6



  • BRILINTA, like other antiplatelet agents, can cause significant, sometimes fatal, bleeding
  • Do not use BRILINTA in patients with active pathological bleeding or a history of intracranial hemorrhage
  • Do not start BRILINTA in patients planned to undergo urgent coronary artery bypass graft surgery (CABG). When possible, discontinue BRILINTA at least 5 days prior to any surgery
  • Suspect bleeding in any patient who is hypotensive and has recently undergone coronary angiography, percutaneous coronary intervention (PCI), CABG, or other surgical procedures in the setting of BRILINTA
  • If possible, manage bleeding without discontinuing BRILINTA. Stopping BRILINTA increases the risk of subsequent cardiovascular events


  • Maintenance doses of aspirin above 100 mg reduce the effectiveness of BRILINTA and should be avoided. After any initial dose, use with aspirin 75 mg - 100 mg per day


  • BRILINTA is contraindicated in patients with a history of intracranial hemorrhage and active pathological bleeding such as peptic ulcer or intracranial hemorrhage. BRILINTA is also contraindicated in patients with severe hepatic impairment because of a probable increase in exposure; it has not been studied in these patients. Severe hepatic impairment increases the risk of bleeding because of reduced synthesis of coagulation proteins


  • Moderate Hepatic Impairment: Consider the risks and benefits of treatment, noting the probable increase in exposure to ticagrelor
  • Premature discontinuation increases the risk of MI, stent thrombosis, and death
  • Dyspnea was reported in 14% of patients treated with BRILINTA and in 8% of patients taking clopidogrel. Dyspnea resulting from BRILINTA is self-limiting. Rule out other causes
  • BRILINTA is metabolized by CYP3A4/5. Avoid use with strong CYP3A inhibitors and potent CYP3A inducers. Avoid simvastatin and lovastatin doses >40 mg
  • Monitor digoxin levels with initiation of, or any change in, BRILINTA therapy


  • The most commonly observed adverse reactions associated with the use of BRILINTA vs clopidogrel were Total Major Bleeding (11.6% vs 11.2%) and dyspnea (14% vs 8%)
  • In clinical studies, BRILINTA has been shown to increase the occurrence of Holter-detected bradyarrhythmias. PLATO excluded patients at increased risk of bradycardic events. Consider the risks and benefits of treatment

Please read full Prescribing Information, including Boxed WARNINGS, and Medication Guide. This information can be found at

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit.

For patients that require BRILINTA beyond their hospital stay, a savings card program is available based on eligibility. Commercially insured and cash-paying patients may be eligible for one free 30-day prescription and can save up to $825 per year on their next 11 refills. For each refill (a 30-day supply of up to 60 tablets), savings may apply after the first $18 spent by a patient, up to a $75 savings limit. Patients covered through Medicare, Medicaid or similar federal or state programs may be eligible for one month free prescription. Patients can find out more at or by calling 1-888-412-7454.

AstraZeneca also offers a U.S. patient assistance program for BRILINTA through its AZ&MeTM Prescription Savings Program. To determine eligibility, patients can visit or call 1-800-AZandMe (292-6363).


About BRILINTA® (ticagrelor) tablets

BRILINTA is an oral antiplatelet treatment for ACS. BRILINTA is a direct-acting P2Y12 receptor antagonist in a chemical class called cyclopentyltriazolopyrimidines (CPTPs). BRILINTA works by inhibiting platelet activation and has been shown to reduce the rate of thrombotic CV events, such as a heart attack or CV death, in patients with ACS.

BRILINTA is available in 90-mg tablets to be administered with a single 180-mg oral loading dose (two 90-mg tablets) followed by a twice daily, 90-mg maintenance dose. Following an initial loading dose of aspirin, BRILINTA should be used with a maintenance dose of 75 mg - 100 mg aspirin once daily, 81-mg aspirin dose in the US.

BRILINTA is a registered trademark of the AstraZeneca group of companies.


PLATO (PLATelet Inhibition and Patient Outcomes) was a large (18,624 patients in 43 countries), head-to-head patient outcomes study of BRILINTA vs clopidogrel, both given in combination with aspirin and other standard therapy. The study was designed to establish whether BRILINTA could achieve a clinically meaningful reduction in cardiovascular (CV) events in acute coronary syndrome (ACS) patients, above and beyond that afforded by clopidogrel. Patients were treated for at least 6 months and up to 12 months.

PLATO demonstrated that treatment with BRILINTA led to a significantly greater reduction in the primary end point - a composite of CV death, MI, or stroke - compared to patients who received clopidogrel (9.8% vs 11.7% at 12 months; 1.9% absolute risk reduction [ARR]; 16% relative risk reduction [RRR]; 95% CI, 0.77 to 0.92; P<0.001). The difference in treatments was driven by CV death and MI with no difference in stroke. In PLATO, the absolute difference in treatment benefit vs clopidogrel was seen at 30 days and the Kaplan-Meier survival curves continued to diverge throughout the 12-month treatment period.

The PLATO study also demonstrated that treatment with BRILINTA for 12 months was associated with a 21% RRR in CV death (4% vs 5.1%; 1.1% ARR; P=0.001) and a 16% RRR in MI compared to clopidogrel at 12 months (5.8% vs 6.9%; 1.1% ARR; P<0.005).

The primary safety end point in the PLATO study was Total Major Bleeding (11.6% for BRILINTA and 11.2% for clopidogrel). In PLATO, non-CABG major + minor bleeding events were more common with BRILINTA vs clopidogrel (8.7% vs 7% respectively). The rate of non-CABG-related major bleeding was higher for BRILINTA (4.5%) vs clopidogrel (3.8%).

Dyspnea was reported in 14% of patients treated with BRILINTA and in 8% of patients treated with clopidogrel. Dyspnea was usually mild to moderate in intensity and often resolved during continued treatment.

About Acute Coronary Syndrome (ACS)

ACS is an umbrella term for conditions that result from insufficient blood supply to the heart muscle. These conditions range from unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), or ST-elevation myocardial infarction (STEMI).

About AstraZeneca

AstraZeneca is a global, innovation-driven biopharmaceutical business with a primary focus on the discovery, development and commercialization of prescription medicines for gastrointestinal, cardiovascular, neuroscience, respiratory and inflammation, oncology and infectious disease. AstraZeneca operates in over 100 countries and its innovative medicines are used by millions of patients worldwide.

For more information about AstraZeneca in the US or our AZ&Me™ Prescription Savings programs, please visit: or call 1-800-AZandMe (292-6363).


O'Gara, P. et al. Circulation. 2012. doi:10.1161/cir.0b013e3182742cf6


Jneid, H. et. al. Journal of the American College of Cardiology. 2012. doi:10.1016/j.jacc.2012.06.004


Guyatt, G. et. al. Chest. 2012. doi:10.1378/chest.1412S3


Levine, G. et. al. Journal of the American College of Cardiology. 2011. doi:10.1016/j.jacc.08.007


Smith, S. et. al. Circulation. 2011. doi:10.1161/cir.0b013e318235eb4d


Hillis, D. et. al. Journal of the American College of Cardiology. 2011. doi:10.1016/j.jacc.2011.08.009


Steg, G. et. al. European Heart Journal. 2012. doi:10.1093/eurheartj/ehs215


Hamm, C. et. al. European Heart Journal. 2011. doi:10.1093/eurheartj/ehr236


Wijns, W. et. al. European Heart Journal. 2010. doi:10.1093/eurheartj/ehq277


Perk, J. et. al. European Heart Journal. 2012. doi:10.1093/eurheartj/ehs092


Bell, A. et. al. Canadian Journal of Cardiology. 2011. doi:10.1016/j.cjca.2010.12.015

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