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Clinically Driven Revascularization in High-Risk Patients Treated With Ticagrelor Monotherapy After PCI: Insights
Usman Baber1, Alessandro Spirito2, Samantha Sartori2
1Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
Insights
Ticagrelor monotherapy after initial dual antiplatelet therapy showed similar rates of repeat revascularization and major adverse events compared to ticagrelor plus aspirin. However, ticagrelor monotherapy significantly reduced net adverse clinical events in high-risk patients post-percutaneous coronary intervention.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Repeat coronary revascularization is a frequent complication following successful percutaneous coronary intervention (PCI).
- High-risk patients undergoing PCI often require prolonged antiplatelet therapy to prevent adverse cardiovascular events.
Purpose of the Study:
- To evaluate the efficacy of ticagrelor monotherapy in reducing repeat clinically driven revascularization (CDR) in high-risk patients after PCI.
- To compare major adverse cardiovascular and cerebrovascular events (MACCEs) and net adverse clinical events (NACEs) between ticagrelor monotherapy and ticagrelor plus aspirin.
Main Methods:
- Analysis of data from the TWILIGHT trial, involving high-risk patients randomized to ticagrelor monotherapy or ticagrelor plus aspirin for 1 year after an initial 3-month dual antiplatelet therapy period.
- The primary endpoint was CDR within 12 months. Secondary endpoints included MACCEs and NACEs.
Main Results:
- Ticagrelor monotherapy demonstrated similar 12-month rates of CDR (7.1% vs 6.6%) and MACCEs (8.9% vs 8.6%) compared to ticagrelor plus aspirin.
- Ticagrelor monotherapy was associated with a significantly lower risk of NACEs (12.2% vs 14.6%, HR 0.83, p=0.004).
- CDR was independently associated with a higher risk of subsequent death, myocardial infarction, or stroke (aHR 2.92).
Conclusions:
- In high-risk patients post-PCI, ticagrelor monotherapy following 3 months of dual antiplatelet therapy is a viable strategy with similar CDR and MACCE risks.
- Ticagrelor monotherapy significantly reduces NACEs, offering a potentially safer alternative for selected patients by decreasing bleeding events.
- These findings support individualized antiplatelet strategies to balance efficacy and safety after PCI.
Abstract:
Repeat coronary revascularization is a common adverse event after successful percutaneous coronary intervention. This analysis aimed to assess the effects of ticagrelor monotherapy on repeat clinically driven revascularization (CDR). In the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients after Coronary Intervention) trial, after 3 months of ticagrelor plus aspirin, high-risk patients were maintained on ticagrelor and randomly allocated to aspirin or placebo for 1 year. The primary end point of this analysis was CDR within 12 months after randomization. The key secondary end points were major adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause death, myocardial infarction, stroke, or CDR, and net adverse clinical events (NACEs), including the individual components of MACCEs and clinically relevant bleeding. The analysis was performed in the per-protocol population. CDR occurred in 473 of 7,039 patients and was associated with a significantly higher risk of subsequent all-cause death, myocardial infarction, or stroke (adjusted hazard ratios [HRs] 2.92, 95% confidence interval [CI] 1.82 to 4.67). Ticagrelor monotherapy was associated with a similar 12-month risk of CDR (7.1% vs 6.6%; HR 1.09, 95% CI 0.90 to 1.30, p = 0.363) and MACCEs (8.9% vs 8.6%; HR 1.04, 95% CI 0.89 to 1.22, p = 0.619), and a lower risk of NACEs (12.2% vs 14.6%; HR 0.83 95% CI 0.73 to 0.94, p = 0.004) than ticagrelor plus aspirin. In conclusion, among high-risk patients who underwent percutaneous coronary intervention, ticagrelor monotherapy after 3 months of ticagrelor-based dual antiplatelet therapy was associated with a similar risk of CDR and MACCEs and a decrease of NACEs (TWILIGHT: NCT02270242).
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