Ticagrelor monotherapy safe, effective for ACS patients post-stent, reduces bleeding by 46%

A recent study showed that using ticagrelor monotherapy is both effective and safe for patients with acute  coronary syndrome (ACS) who have received drug-eluting stent (DES) implantation and short-term dual antiplatelet therapy (DAPT) for less than three months.

A research team led by professors Hong Myeong-ki and Lee Yong-joon from Severance Cardiovascular Hospital, Yonsei University College of Medicine,  said on Friday that maintaining the use of ticagrelor alone after undergoing DES implantation and DAPT for less than three months in patients with ACS resulted in no significant difference in ischemia compared with the standard ticagrelor-based 12-month long-term DAPT, while reducing bleeding  by approximately 46 percent.

The study was recently published in the latest issue of the European Heart Journal (IF 39.3). 

DAPT stands as a crucial measure in preventing ischemia, such as myocardial infarction and strokes, in ACS patients who have undergone DES implantation. Given the heightened vulnerability of  ACS patients to ischaemia compared to those with stable angina (angina pectoris), both the American College of Cardiology (ACC) and the European Society of Cardiology (ESC) advocate for a 12-month regimen of DAPT featuring ticagrelor. Ticagrelor, a potent antiplatelet agent, facilitates smoother blood flow through the veins, thereby reducing the likelihood of dangerous blood clot formation.

While prolonged and potent DAPT reduces the likelihood of ischemia, it can increase the risk of bleeding. This calls for the need of an antiplatelet regimen that balances the prevention of both types of events.

To address this, the researchers undertook a meta-analysis of individual patient data drawn from the TICO and T-PASS trials. These randomized multi-center clinical trials, conducted on Korean patients, provided the foundation for the researchers' investigation.

TICO compared the effectiveness of ticagrelor monotherapy after 12 months of DAPT versus three months of DAPT in 3,056 Korean patients with ACS . T-PASS expanded on the TICO study to compare the effectiveness of ticagrelor monotherapy after 12 months of DAPT versus less than one month of DAPT in 2,850 Korean patients with ACS.

The researchers conducted a meta-analysis of one-year ischemic and major bleeding events, including total mortality, myocardial infarction, or stroke, alongside major bleeding events (BARC types thre eand five) across 5,906 ACS patients from both studies.

The analysis revealed no significant disparity in the occurrence of ischemia during the one-year follow-up between the 12-month DAPT arm and the ticagrelor monotherapy arm. However, the ticagrelor monotherapy arm exhibited an approximate 46 percent reduction in the incidence of major bleeding. This trend held true across various demographic factors including age, sex, clinical presentation, and stent length.

The researchers also investigated the generalizability of these findings beyond the local patient population to an international context.

They conducted a secondary aggregate data meta-analysis, merging subgroup analyses from two randomized clinical trials: the TWILIGHT study, led by researchers in the U.S., and the GLOBAL LEADERS study, led by researchers in Europe. Both involved patients with ACS.

Incorporating data from international patients, the study revealed that the ticagrelor monotherapy arm exhibited equivalent rates of ischemia and a diminished occurrence of major bleeding events compared to the 12-month DAPT arm, mirroring the results observed in the Korean cohort.

“We confirmed the superiority of ticagrelor monotherapy after short-term DAPT of three months or less after stenting in patients with ACS,” said Professor Hong. “Based on these findings, we expect to provide patients with more effective and safer treatment.”