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Ticagrelor monotherapy in ST-elevation myocardial infarction: An individual patient-level meta-analysis from TICO and
Yong-Joon Lee1, Deok-Kyu Cho2, Jun-Won Lee3
1Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
Insights
Ticagrelor monotherapy after short dual antiplatelet therapy (DAPT) in ST-elevation myocardial infarction (STEMI) patients showed similar efficacy but significantly reduced major bleeding compared to 12-month DAPT. This suggests a safer alternative for STEMI patients with drug-eluting stents.
Area of Science:
- Cardiology
- Clinical Trials
- Pharmacology
Background:
- ST-elevation myocardial infarction (STEMI) patients are under-represented in trials of P2Y12 inhibitor monotherapy.
- Evaluating potent P2Y12 inhibitor monotherapy after short dual antiplatelet therapy (DAPT) is crucial for STEMI management.
Purpose of the Study:
- To compare ticagrelor monotherapy versus ticagrelor-based DAPT in STEMI patients undergoing drug-eluting stent (DES) implantation.
- To assess the efficacy and safety outcomes of these treatment strategies at one year.
Main Methods:
- Pooled individual patient data from randomized clinical trials involving STEMI patients with DES.
- Comparison of ticagrelor monotherapy (≤3 months DAPT) against 12-month ticagrelor-based DAPT.
- Co-primary outcomes: efficacy (death, MI, stroke) and safety (BARC 3/5 bleeding) at 1 year.
Main Results:
- The primary efficacy outcome did not differ significantly between ticagrelor monotherapy and DAPT groups (1.8% vs 2.0%).
- Ticagrelor monotherapy was associated with a significantly lower incidence of major bleeding (2.3% vs 4.0%).
- No significant difference in cardiac death or heterogeneity of treatment effects across subgroups was observed.
Conclusions:
- Ticagrelor monotherapy after short-term DAPT is a safe and effective strategy for STEMI patients treated with DES.
- This approach reduces major bleeding risk without compromising ischemic event prevention.
- Further research is needed to confirm these findings in non-Asian populations.
Background:
Patients with ST-elevation myocardial infarction (STEMI) tend to be excluded or under-represented in randomized clinical trials evaluating the effects of potent P2Y12 inhibitor monotherapy after short-term dual antiplatelet therapy (DAPT).
Methods:
Individual patient data were pooled from randomized clinical trials that included STEMI patients undergoing drug-eluting stent (DES) implantation and compared ticagrelor monotherapy after short-term (≤3 months) DAPT versus ticagrelor-based 12-month DAPT in terms of centrally adjudicated clinical outcomes. The co-primary outcomes were efficacy outcome (composite of all-cause death, myocardial infarction, or stroke) and safety outcome (Bleeding Academic Research Consortium type 3 or 5 bleeding) at 1 year.
Findings:
The pooled cohort contained 2,253 patients with STEMI. The incidence of the primary efficacy outcome did not differ between the ticagrelor monotherapy group and the ticagrelor-based DAPT group (1.8% versus 2.0%; hazard ratio [HR] = 0.88; 95% confidence interval [CI] = 0.49-1.61; p = 0.684). There was no difference in cardiac death between the groups (0.6% versus 0.7%; HR = 0.89; 95% CI = 0.32-2.46; p = 0.822). The incidence of the primary safety outcome was significantly lower in the ticagrelor monotherapy group (2.3% versus 4.0%; HR = 0.56; 95% CI = 0.35-0.92; p = 0.020). No heterogeneity of treatment effects was observed for the primary outcomes across subgroups.
Conclusions:
In patients with STEMI treated with DES implantation, ticagrelor monotherapy after short-term DAPT was associated with lower major bleeding without an increase in the risk of ischemic events compared with ticagrelor-based 12-month DAPT. Further research is necessary to extend these findings to non-Asian patients.
Funding:
This study was funded by Biotronik (Bülach, Switzerland).
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