Ticagrelor alone after DAPT lowers bleeding risk among heart attack patients undergoing PCI
Ticagrelor monotherapy lowers the risk of bleeding events among high-risk percutaneous coronary intervention (PCI) patients with a history of myocardial infarction (MI), according to new findings published in JACC: Cardiovascular Interventions.[1]
In a new analysis of data from the international TWILIGHT study, researchers focused on the impact a prior MI may have on clinical outcomes after PCI. More than 6,500 patients were included in the team’s assessment, with 29.7% presenting with a prior MI and the remaining 70.3% presenting with no such history. Patients were treated at one of 187 hospitals from 11 different countries that participated in the TWILIGHT study.
All patients were initially prescribed dual antiplatelet therapy (DAPT) with ticagrelor and aspirin for three months after PCI. After those three months of DAPT, participants with no major ischemic or bleeding events were randomized to either take ticagrelor and aspirin or ticagrelor and a placebo for the following 12 months.
After those 12 months, the rate of mortality, MI or stroke was higher among patients with a prior MI than it was among patients with no prior MI. Bleeding Academic Research Consortium (BARC) types 2 to 5 bleeding events, however, occurred at similar rates in the two groups
“Despite remarkable improvements in short-term prognosis, patients who survive acute MI remain at increased risk for recurrent atherothrombotic events and reduced long-term survival,” wrote co-first authors Mauro Chiarito, MD, and Usman Baber, MD, specialists with the Icahn School of Medicine at Mount Sinai in New York City, and colleagues. “Intensifying antithrombotic therapy by using potent antiplatelet agents significantly reduces the risk for ischemic events, although at a cost of increased rate of bleeding events. Nonetheless, residual atherothrombotic risk remains substantial among patients with prior MI, an epidemiologic pattern consistent with our results.”
Looking at the two treatment strategies, ticagrelor monotherapy was consistently associated with a lower 12-month risk of BARC types 2 to 5 bleeding events. Among patients with a prior MI, these major bleeding events were seen in 3.4% of patients on ticagrelor alone and 6.7% of patients on ticagrelor and aspirin. Among patients with no prior MI, these events were seen in 4.2% of patients on ticagrelor alone and 7% of patients on ticagrelor and aspirin.
The authors also noted that the composite 12-month rate of all-cause mortality, MI or stroke was similar between the two treatment groups.
“Ticagrelor monotherapy significantly reduced clinically relevant and major bleeding compared with ticagrelor plus aspirin in patients with histories of MI, without any apparent trade-off in ischemic risk,” the authors wrote. “These findings were consistent in patients with prior MI who also met the PEGASUS-TIMI 54 inclusion criteria. However, the relatively small sample size prompts the need for larger studies evaluating ticagrelor monotherapy in patients with prior MI.”
AstraZeneca, the company that sells ticagrelor under the name Brilinta, did help fund this analysis. Also, multiple authors reported a prior relationship with AstraZeneca.
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