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Ticagrelor Monotherapy After 3-Month Dual Antiplatelet Therapy in Acute Coronary Syndrome by High Bleeding Risk: The
Yong-Joon Lee1, Yongsung Suh2, Jung-Sun Kim3
1Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
Insights
Ticagrelor monotherapy after 3-month dual antiplatelet therapy (DAPT) reduces adverse events in acute coronary syndrome (ACS) patients with drug-eluting stents (DESs). This benefit was observed regardless of high bleeding risk (HBR) status, suggesting a consistent therapeutic effect.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Identifying patients with high bleeding risk (HBR) is crucial for guiding antiplatelet therapy post-acute coronary syndrome (ACS).
- Dual antiplatelet therapy (DAPT) is standard, but prolonged DAPT increases bleeding risk, necessitating risk stratification.
- Drug-eluting stents (DESs) are widely used in ACS, making optimal antiplatelet strategies essential.
Purpose of the Study:
- To evaluate the efficacy and safety of ticagrelor monotherapy versus ticagrelor-based DAPT after an initial 3-month DAPT period in ACS patients treated with DESs.
- To assess the impact of high bleeding risk (HBR) on the outcomes of ticagrelor monotherapy versus DAPT.
- To determine if the therapeutic effect of ticagrelor monotherapy is consistent across patients with and without HBR.
Main Methods:
- Post-hoc analysis of the TICO trial involving 2,980 patients treated with DESs.
- High bleeding risk (HBR) was defined using Academic Research Consortium for HBR (ARC-HBR) criteria and the PRECISE-DAPT score (≥25).
- The primary outcome was a composite of major bleeding and adverse cardiac and cerebrovascular events from 3 to 12 months post-stent implantation.
Main Results:
- 15.2% and 16.9% of patients were identified as HBR by ARC-HBR and PRECISE-DAPT criteria, respectively.
- HBR patients had a significantly higher rate of net adverse clinical events compared to non-HBR patients (HR 2.87-3.09).
- Ticagrelor monotherapy after 3-month DAPT showed a lower rate of net adverse clinical events compared to 12-month DAPT, irrespective of HBR status (p-interaction=0.400 for ARC-HBR, p-interaction=0.178 for PRECISE-DAPT).
Conclusions:
- Ticagrelor monotherapy following a 3-month DAPT regimen is associated with reduced adverse clinical outcomes in ACS patients treated with DESs.
- The benefit of ticagrelor monotherapy was consistent across patients with and without high bleeding risk.
- These findings support ticagrelor monotherapy as a viable strategy regardless of bleeding risk in selected ACS patients.
Background And Objectives:
Identifying patients with high bleeding risk (HBR) is important when making decisions for antiplatelet therapy strategy. This study evaluated the impact of ticagrelor monotherapy after 3-month dual antiplatelet therapy (DAPT) according to HBR in acute coronary syndrome (ACS) patients treated with drug eluting stents (DESs).
Methods:
In this post-hoc analysis of the TICO trial, HBR was defined by 2 approaches: meeting Academic Research Consortium for HBR (ARC-HBR) criteria or Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent DAPT (PRECISE-DAPT) score ≥25. The primary outcome was a 3-12 months net adverse clinical event (composite of major bleeding and adverse cardiac and cerebrovascular events).
Results:
Of the 2,980 patients without adverse events during the first 3 months after DES implantation, 453 (15.2%) were HBR by ARC-HBR criteria and 504 (16.9%) were HBR by PRECISE-DAPT score. The primary outcome rate was higher in HBR versus non-HBR patients (by ARC-HBR criteria: hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.76-4.69; p<0.001; by PRECISE-DAPT score: HR, 3.09; 95% CI, 1.92-4.98; p<0.001). Ticagrelor monotherapy after 3-month DAPT was associated with lower primary outcome rate than ticagrelor-based 12-month DAPT regardless of HBR by ARC-HBR criteria, with similar magnitudes of therapy effect for HBR and non-HBR patients (p-interaction=0.400). Results were consistent by PRECISE-DAPT score (p-interaction=0.178).
Conclusions:
In ACS patients treated with DESs, ticagrelor monotherapy after 3-month DAPT was associated with lower rate of adverse clinical outcomes regardless of HBR, with similar magnitudes of therapy effect between HBR and non-HBR.
Trial Registration:
ClinicalTrials.gov Identifier: NCT02494895.
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