Ticagrelor monotherapy reduces bleeding risk compared to dual antiplatelet therapy for patients following coronary stenting

1. Ticagrelor was non-inferior to DAPT for the incidence of major adverse cardiovascular and cerebrovascular events.

2. Ticagrelor monotherapy significantly reduced the likelihood of BARC 3 or 5 bleeding.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Patients with acute coronary syndrome (ACS) receive dual antiplatelet therapy (DAPT) for 12 months post-stenting to reduce the risk of adverse cardiovascular events. However, there is growing interest in whether de-escalating from DAPT to ticagrelor monotherapy can achieve similar protective effects while minimizing bleeding risk. This systematic review and meta-analysis aimed to compare the efficacy and safety of ticagrelor monotherapy after short-term DAPT versus the standard 12-month DAPT in patients undergoing coronary stent implantation. The primary outcome of this study was the rate of major adverse cardiovascular or cerebrovascular events (MACCE), while key secondary outcome was the occurrence of major bleeding events. According to study results, ticagrelor monotherapy showed a similar risk of MACCE while the risk of major bleeding was significantly reduced, especially in patients with ACS. Although this study was well done, it was limited by the exclusion of patients requiring long-term oral anticoagulation, which may restrict the generalizability of findings.

Click to read the study in The Lancet

Relevant Reading: Ticagrelor with or without Aspirin in High-Risk Patients after PCI

In-depth [systematic review and meta-analysis]: 8361 articles were screened for eligibility in Ovid MEDLINE, Embase, and two websites, from database inception to May 20, 2024. Included were trials in which patients underwent coronary stenting with drug-eluting stents and were not on long-term oral anticoagulants following acute coronary syndrome (ACS). Altogether, 24,407 patients (12 199 in ticagrelor and 12 208 in DAPT) were included in the final analysis. The primary outcome of major adverse cardiovascular or cerebrovascular events (MACCE) showed that ticagrelor monotherapy was non-inferior to DAPT in reducing these events (297 in ticagrelor vs. 332 in DAPT, hazard ratio [HR] 0.91, p=0.0039). The secondary outcome of Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding revealed a significantly lower risk with ticagrelor monotherapy (0.9% vs. 2.1%, HR 0.43, p<0.0001). Overall, findings from this study suggest that de-escalation to ticagrelor monotherapy reduces major bleeding risk without increasing ischemic events, particularly benefiting patients with ACS.

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