Breaking boundaries: Ticagrelor monotherapy in high-risk patients

Area of Science:

• Cardiovascular Medicine
• Pharmacology
• Interventional Cardiology

Background:

• Atherosclerotic plaque rupture causes arterial thrombosis, leading to major adverse cardiovascular events (MACE) like myocardial infarction and stroke.
• Dual antiplatelet therapy (DAPT), combining aspirin and a P2Y12 inhibitor, is standard post-percutaneous coronary intervention (PCI) but increases bleeding risk, especially in high bleeding risk (HBR) patients.

Purpose of the Study:

• To review the efficacy and safety of ticagrelor monotherapy as a strategy to reduce bleeding risk in HBR patients following short-term DAPT after PCI.
• To discuss optimal timing, patient selection, and treatment duration for ticagrelor monotherapy in this population.

Main Methods:

• Review of clinical trials (TICO, TWILIGHT, GLOBAL LEADERS, ULTIMATE-DAPT) and meta-analyses evaluating ticagrelor monotherapy versus conventional DAPT or other monotherapies.
• Analysis of ticagrelor's efficacy across diverse patient subgroups and its impact on mortality and clinical adverse events.

Main Results:

• Ticagrelor monotherapy demonstrates superiority over aspirin or clopidogrel monotherapy in reducing ischemic events and mortality.
• Evidence from major trials and meta-analyses supports ticagrelor monotherapy's role in lowering adverse events compared to standard DAPT.
• This strategy effectively balances ischemic protection with reduced bleeding risk.

Conclusions:

• A personalized treatment approach, starting with DAPT followed by ticagrelor monotherapy, is recommended for acute coronary syndrome patients post-PCI, particularly those at high bleeding risk.
• Ticagrelor monotherapy offers a favorable risk-benefit profile for managing both ischemic and bleeding complications.