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Fewer adverse events with ticagrelor monotherapy after 3 months DAPT

Presented by
Prof. Y.S. Jang, Yonsei University, South Korea
ACC 2020
Ticagrelor monotherapy after 3-month dual antiplatelet therapy (DAPT) has shown a significantly lower risk of net adverse clinical events (NACE) than the currently recommended 12-month DAPT with ticagrelor and aspirin, with the reduced risk mainly due to decreased major bleeding [1]. 

The objective of the TICO trial, presented by Prof. Yang Soo Jang (Yonsei University, South Korea), was to investigate ticagrelor monotherapy after 3 months of DAPT versus ticagrelor-based, 12-month DAPT for patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI) with new-generation, drug-eluting stents. The study enrolled 3,065 ACS patients (mean age 61 years) undergoing PCI with second-generation, ultrathin, biodegradable, polymer-coated, sirolimus-eluting stents. All patients received ticagrelor plus aspirin for 3 months after which they were randomised to continue treatment with ticagrelor alone (n=1,527) or ticagrelor and aspirin (n=1,529). The primary study endpoint was a net clinical benefit composite of death, myocardial infarction, stroke, stent thrombosis, revascularisation, or Thrombolysis in Myocardial Infarction (TIMI) major bleeding at 12 months.

The results showed that 3.9% of patients on ticagrelor monotherapy experienced a primary endpoint event compared with 5.9% of patients continuing DAPT (HR 0.66; P=0.01). Interestingly, there was a clear difference in event rate at 3 months after randomisation with 1.4% of ticagrelor monotherapy patients achieving the composite endpoint versus 3.5% of those continuing DAPT (HR 0.41; P=0.001). At 12 months, TIMI major bleeding was present in 1.7% of patients on ticagrelor monotherapy versus 3% of continuing DAPT patients (HR 0.56; P=0.02). No difference was observed in ischaemic events between the 2 groups (2.3% with ticagrelor monotherapy vs 3.4% with 12-month DAPT; HR 1.51; 95% CI 0.43-5.33; P=0.53). Although the study had some limitations, such as the open-label design, no placebo group, and exclusion of patients with an elevated risk for bleeding, the authors concluded that ticagrelor monotherapy could be an optimal strategy balancing both ischaemic and bleeding risks for patients with ACS. It should be noted that this study was not powered for ischaemic endpoints and therefore observations and conclusions should be limited to safety.

    1. Kim B-K, et al. Abstract 410-08. ACC/WCC 28-30 March 2020.


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