Abstract Body (Do not enter title and authors here): Introduction:
Ticagrelor is a more potent P2Y12 inhibitor compared to clopidogrel and is commonly used in the treatment of stable coronary artery disease (CAD), including after percutaneous coronary intervention (PCI). However, hepatic metabolism of these agents may be altered in patients with cirrhosis, and comparative clinical outcomes in this population remain underexplored.

Research Questions:
What are the cardiovascular and safety outcomes of ticagrelor versus clopidogrel in cirrhotic patients with stable CAD following PCI?

Methods:
We conducted a retrospective cohort study using the Global Collaborative Network TriNetX, including data from January 2015 to January 2025. Patients with cirrhosis and stable CAD who underwent PCI were identified and categorized based on receipt of ticagrelor or clopidogrel. Propensity score matching was employed to balance baseline characteristics, including demographics, comorbidities, laboratory values, and concomitant medications.

Results:
After matching, 1,591 patients were included in each group, with no significant differences in baseline characteristics. Over a 3-year follow-up period, ticagrelor use was associated with a significantly higher risk of acute myocardial infarction (MI) (HR 1.419, 95% CI: 1.252–1.607, P < 0.0001) and major adverse cardiovascular events (MACE) (HR 1.223, 95% CI: 1.112–1.344, P < 0.0001). There were no significant differences in all-cause mortality (HR 1.047, 95% CI: 0.924–1.187, P = 0.471), major bleeding (HR 0.927, 95% CI: 0.793–1.083, P = 0.3367), or stroke (HR 0.852, 95% CI: 0.676–1.074, P= 0.1756).

Conclusion:
In cirrhotic patients undergoing PCI for stable CAD, ticagrelor was unexpectedly associated with higher risks of acute MI and MACE compared to clopidogrel, without a corresponding increase in bleeding or mortality. These findings highlight the need for prospective studies to further investigate antiplatelet therapy choice in this unique population.