Ticagrelor Monotherapy after 3 Months: Is the Current Strategy Worth Changing?

Dual antiplatelet therapy (DAPT) after PCI with DES has shown noticeable reduction of thrombotic events, especially in acute coronary syndromes (ACS). However, this therapy encompasses increased bleeding, especially in elderly patients increasingly undergoing percutaneous intervention. Even though most bleeding events might not be fatal (many of them are mostly digestive) they do involve higher hospitalization rate and therefore higher health cost.

Research on the use of short term DAPT is not new, and outcomes so far have been promising; however, its indication in ACS patients remains unclear.

The present prespecified analysis of the randomized TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) compares patients with and without prior acute myocardial infarction (AMI), with special attention to evolution with 12 month DAPT vs 3 month DAPT followed by ticagrelor monotherapy + placebo at 12 months.

6532 patients were randomized: 4595 without prior AMI (70.3%) and 1937 with prior AMI (29,7%).

There were no significant differences between the populations, except for smoking and multivessel disease in patients receiving ticagrelor + aspirin among patients with no prior MI. Among the patients with prior MI there was a higher proportion of insulin dependent diabetes, dyslipidemia, hypertension, multivessel disease, PCI and CABG.

At one-year followup, global bleeding rate was similar between patients with and without prior AMI (5% vs. 5.5% respectively). However, looking at patients who had received ticagrelor + placebo, the group with prior MI presented less bleeding when compared against patients with no prior MI (3.4% vs. 6.7%; HR: 0.50; 95% CI: 0.33-0.76 and 4.2% vs 7.0%; HR: 0.58; 95% CI:0.45-0.76 respectively).

The presence of death, AMI or stroke was higher in patients with prior AMI (5.7% vs 3.2%; P < 0.001).

There were no differences in cardiac death, non-fatal infarction, non-fatal stroke, BARC bleeding 2.3 or 5, definite or probable thrombosis.

Conclusion

Ticagrelor monotherapy is associated with a significant reduction of bleeding events compared against ticagrelor + aspirin, with no compromise of ischemic prevention among high-risk patients with a history of MI undergoing PCI.