Patient selection for long-term secondary prevention with ticagrelor: insights from PEGASUS-TIMI 54

Area of Science:

• Cardiology
• Pharmacology

Background:

• Patients with prior myocardial infarction (MI) on aspirin face increased bleeding risk with ticagrelor.
• Assessing both ischemic and bleeding risk is crucial for optimal ticagrelor use.

Purpose of the Study:

• To evaluate the risk-benefit profile of long-term ticagrelor in prior MI patients based on bleeding and ischemic risk.
• To identify patient subgroups most likely to benefit from ticagrelor therapy.

Main Methods:

• The PEGASUS-TIMI 54 trial randomized 13,956 prior MI patients to ticagrelor or placebo.
• Patients were stratified into groups based on bleeding predictors and ischemic risk factors (IRFs).
• Primary efficacy endpoint: cardiovascular death, MI, or stroke; primary safety outcome: TIMI major bleeding.

Main Results:

• In high bleeding risk patients, ticagrelor increased bleeding and did not reduce the primary efficacy endpoint.
• In low bleeding risk patients, ticagrelor showed greater efficacy with increasing numbers of IRFs (≤1, 2, or ≥3).
• Significant trends for greater risk reduction in cardiovascular death, all-cause mortality, and net outcomes were observed with ticagrelor across low bleeding risk groups with more IRFs.

Conclusions:

• Long-term ticagrelor therapy is most suitable for prior MI patients with multiple ischemic risk factors and low bleeding risk.
• Risk stratification is essential for tailoring ticagrelor therapy to individual patient profiles.
• Further research may refine patient selection for optimal ticagrelor use.