Just when we were starting to understand how long dual antiplatelet therapy should be for our patients, JACC publishes this study where ticagrelor combined with aspirin significantly reduces relative and absolute events rate at long term, especially in patients with multivessel disease.

The PEGASUS-TIMI 54 assessed the long-term benefits of two different doses of ticagrelor (60 mg or 90 mg every 12 hrs.) compared against placebo in patients with a history of MI and additional risk factors treated with low doses of aspirin.

This analysis of patients with multivessel disease was prespecified in the protocol.

The study evaluated the composite of cardiovascular death, MI or stroke (MACE), in addition to the composite to cardiac death, MI, stent thrombosis, TIMI major bleeding, intracranial bleeding and fatal bleeding at mean 33 months follow-up.

Read also: Clopidogrel or Ticagrelor in Patients with Acute Coronary Syndrome Treated with New-Generation DES: CHANGE DAPT.

A total 12558 patients (59.4% of the whole study population) had multivessel disease. In this group of patients, ticagrelor reduced the risk of combined events (7.94% vs. 9.37%, HR: 0.82; p=0.004) and coronary events (6.02% vs. 7.67%, HR: 0.76; p<0.0001), including 36% reduction of coronary death (HR: 0.64; p=0.002).

As expected, the flipside was an increase in major bleeding, according to TIMI criteria (2.52% vs. 1.08%, HR: 2.67; p<0.0001), though there was no increase of intracranial or fatal bleeding.

Read also: DACAB: Ticagrelor and Aspirin Improve Vein Graft Patency.

In the placebo Branch, patients with multivessel disease had a significantly higher events risk than those with one single culprit vessel.

Conclusion

Patients with a history of infarction and multivessel disease are exposed to a higher risk of events and could benefit from a significant reduction (both relative and absolute) with a long term treatment with ticagrelor in addition to low doses of aspirin.

Ticagrelor did increase bleeding but not intracranial or fatal bleeding. 

Original title: Ticagrelor for Secondary Prevention of Atherothrombotic Events in Patients with Multivessel Coronary Disease.

Reference: Sameer Bansilal et al. J Am Coll Cardiol 2018;71:489–96.

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