Switching to ticagrelor monotherapy after 3 months of dual antiplatelet therapy reduces major bleeding without paying a price in terms of ischemic events, compared with dual antiplatelet therapy for a year, in patients who had acute coronary syndrome and underwent angioplasty with a second-generation drug-eluting stent.

Interrupting aspirin at 3 months and switching it for ticagrelor reduces the risk of net adverse clinical events (a composite of bleeding and major adverse cardiovascular and cerebrovascular events) from 5.9% to 3.9% (hazard ratio [HR]: 0.66).

The difference is mainly driven by a reduction in major bleeding (1.7% vs. 3.0%).

These findings indicate that ticagrelor monotherapy might be the optimal strategy balancing both ischemic and bleeding risks in patients with acute coronary syndromes who received an ultrathin, biodegradable-polymer, sirolimus-eluting stent. This last aspect is the obstacle that hinders the generalization of this strategy.

TICO follows the TWILIGHT trial and all its substudies, which might prompt us to state that ticagrelor is what makes a difference; however, there is evidence indicating that the aforementioned stent type causes less thrombotic events.

Read also: Virtual ACC 2020 | PRECOMBAT: 10 Years for Surgery vs. Angioplasty in Left Main Coronary Artery Disease.

In favor of ticagrelor, patients in the 1-year dual antiplatelet therapy arm also received the ultrathin strut stent.

Daily practice will tell us over time which is the ideal strategy, and which is the real strategy.

In a setting of acute coronary syndrome, most interventional cardiology cath labs have a hard time choosing a device to use. Additionally, there is evidence indicating that costs are the main reason people switch from ticagrelor to clopidogrel, and patients make this decision without asking their primary care physician.

Original Title: Ticagrelor with or without aspirin in acute coronary syndrome after PCI: randomized evaluation of ticagrelor monotherapy after 3-month dual antiplatelet therapy in acute coronary syndrome (the TICO trial).

Reference: Jang Y et al. Presentado en forma virtual en el ACC 2020.

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