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Drop aspirin after 3 months in non-STEMI ACS patients on dual antiplatelet therapy

Presented by
Prof. Usman Baber, Icahn School of Medicine at Mount Sinai, USA
AHA 2019
In a sub-analysis of the TWILIGHT trial, which looked only at patients with acute coronary syndrome (ACS), researchers confirmed that dropping aspirin after 3 months of dual antiplatelet therapy (DAPT) with ticagrelor following percutaneous coronary intervention (PCI) lowers bleeding risk without increasing the rate of ischaemic events. The benefit observed with ticagrelor monotherapy was independent of risk levels or whether the patients had non-ST elevation myocardial infarction (NSTEMI) or unstable angina at presentation.

Prof. Usman Baber (Icahn School of Medicine at Mount Sinai, USA) provided the rationale behind this particular sub-analysis: “The basis for DAPT in ACS really comes from trials conducted almost 20 years ago showing that it is superior to aspirin,” but he noted that “one of the challenges we have with the provision of antiplatelet therapy right now is that a lot of patients who should probably be getting potent agents are not getting them due to concerns of bleeding” [1].

Of the 4,614 ACS patients enrolled in TWILIGHT, 2,494 had unstable angina and 2,120 had NSTEMI. Patients were randomised to drop aspirin after 3 months and continue ticagrelor monotherapy (n=2,273) or to continue with DAPT (n=2,341). Patient characteristics were similar in both groups; the mean age was 64 years, 35% had diabetes, and 61% had multivessel disease. There were, however, more smokers in the continued DAPT arm of the trial (26.6% vs 23.3%; P=0.02).

The primary endpoint at 1 year was Bleeding Academic Research Consortium (BARC) 2, 3, or 5. The results showed that the primary endpoint was met: bleeding was significantly lower in the ticagrelor monotherapy group compared with the arm that continued DAPT (3.6% vs 7.6%; HR 0.47; 95% CI 0.36-0.61; P<0.001). The 2 arms appeared similar for the secondary endpoint of all-cause death, MI, or stroke at 1 year (4.3% vs 4.4%; HR 0.97; 95% CI 0.74-1.28; P=0.84). Neither risk factors at presentation nor whether the patients had presented with unstable angina or NSTEMI made a difference. Prespecified ischaemic endpoints between the 2 arms were similar, including cardiovascular death, all-cause death, any MI, stroke, and stent thrombosis.

1. Baber U, et al. Ticagrelor with aspirin or alone in high-risk patients after coronary intervention for acute coronary syndrome. LBS04, AHA Scientific Sessions 2019, 14-18 November, Philadelphia, USA.

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