Bleeding and Ischemic Risks of Ticagrelor Monotherapy After Coronary Interventions

Area of Science:

• Cardiology
• Pharmacology

Background:

• The TWILIGHT trial investigated ticagrelor monotherapy versus dual antiplatelet therapy (DAPT) in high-risk patients post-percutaneous coronary intervention (PCI).
• Previous strategies involved continuing DAPT with aspirin and ticagrelor after an initial course.

Purpose of the Study:

• To evaluate the clinical net benefit of ticagrelor monotherapy compared to DAPT.
• To individually model bleeding benefits and ischemic risks associated with each treatment strategy.

Main Methods:

• Multivariable Cox regression models were used to assess Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 events and major adverse cardiac and cerebrovascular events (MACCE).
• Risk scores for bleeding and ischemia were calculated for each patient based on model coefficients.
• Stepwise forward variable selection was employed in model development.

Main Results:

• In 7,119 patients, ticagrelor monotherapy consistently reduced bleeding events across all risk strata compared to DAPT.
• This reduction in bleeding was not accompanied by an increase in MACCE, even in high-risk patients.
• The interaction P-values for bleeding and ischemic risk strata were 0.54 and 0.11, respectively.

Conclusions:

• Discontinuing aspirin to maintain ticagrelor monotherapy for three months post-PCI reduces bleeding in high-risk patients.
• This strategy offers a significant bleeding reduction benefit without an apparent increase in ischemic risk.
• The findings support ticagrelor monotherapy as a potentially safer option after PCI in selected high-risk populations.