The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI)
Safety and Efficacy of Ticagrelor Monotherapy According to Drug-Eluting Stent Type: The TWILIGHT-STENT Study
George Dangas1; Usman Baber2; Samin Sharma1; Gennaro Giustino1; Samantha Sartori1; Johny Nicolas1; Ridhima Goel1; Shamir Mehta3; David Cohen4; Dominick J. Angiolillo5; Zhongjie Zhang1; Anton Camaj1; Davide Cao1; Carlo Briguori6; Dariusz Dudek7; Javier Escaned8; Kurt Huber9; Timothy Collier10; Ran Kornowski11; Vijay Kunadian12; David J. Moliterno13; E. Magnus Ohman14; Giora Weisz15; Robert Gil16; Mitchell W. Krucoff14; Upendra Kaul17; Keith Oldroyd18; Gennaro Sardella19; Richard Shlofmitz20; Bernhard Witzenbichler21; Adnan Kastrati22; Ya-ling Han23; Philippe Gabriel Steg24; Stuart Pocock10; C. Michael Gibson25; Roxana Mehran26,
1. The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA 2. The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA. Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA 3. Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada 4. St. Francis Hospital, Roslyn NY and Cardiovascular Research Foundation, New York, NY 5. Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA 6. Mediterranea Cardiocentro, Naples, Italy 7. Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland 8. Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain 9. 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical Faculty, Vienna, Austria 10. Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom 11. Cardiology Department, Rabin Medical Center, Petach Tikva, Israel 12. Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom 13. University of Kentucky, Lexington, KY, USA 14. Duke University Medical Center-Duke Clinical Research Institute, Durham, NC, USA 15. New York Presbyterian Hospital, Columbia University Medical center, NY, USA 16. Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland 17. Batra Hospital and Medical Research Center, New Delhi, India 18. West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom 19. Department of Cardiology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy 20. St. Francis Hospital, Roslyn, NY, USA 21. Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau, Germany 22. Department of Cardiology, Deutsches Herzzentrum Munchen, Lazarettstrabe 36, 80636 Munchen, Germany 23. Department of Cardiology, Shenyang North Hospital, Huanggu Qu, Shenyang Shi, Liaoning Sheng, China 24. Department of Cardiology, Groupe Hospitalier Bichat–Claude-Bernard, 46 Rue Henri Huchard, 75018 Paris, France 25. Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA 26. The Zena and Michael A. Wiener Cardiovascular Institute, Ichan School of Medicine at Mount Sinai, New York, NY, USA
Background: In the TWILIGHT trial, ticagrelor monotherapy after a short course of dual antiplatelet therapy (DAPT) was shown to be a safe bleeding avoidance strategy in high-risk patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES). Aims:To evaluate the effects of ticagrelor monotherapy after 3-month DAPT in patients undergoing PCI, according to DES type. Methods: In the current subanalysis from TWILIGHT, patients were stratified into 3 groups based on DES type: durable polymer everolimus-eluting stents (DP-EES), durable polymer zotarolimus-eluting stents (DP-ZES), and biodegradable polymer DES (BP-DES). Bleeding and ischemic outcomes were assessed at 1 year after randomization. Results: Out of 5,769 patients, 3,014 (52.2%) had DP-EES, 1,350 (23.4%) had DP-ZES and 1,405 (24.4%) had BP-DES. Compared with ticagrelor plus aspirin, ticagrelor monotherapy had significantly lower BARC type 2, 3 or 5 bleeding compared with DAPT; DP-EES (3.8% vs. 6.7%; HR:0.56, 95% CI:0.41-0.78), DP-ZES (4.6% vs. 6.9%; HR:0.66, 95% CI:0.42-1.04) and BP-DES (4.2% vs. 7.9%; HR:0.52, 95% CI:0.33-0.81; pinteraction=0.76). Ticagrelor monotherapy resulted in similar rates of death, MI, or stroke: DP-EES (4.2% vs. 4.3%; HR:0.97; 95% CI:0.68-1.37); DP-ZES (4.1% vs. 3.1%; HR:1.32; 95% CI:0.75-2.33); BP-DES (3.9% vs. 4.2%; HR:0.92; 95% CI:0.54-1.55; pinteraction=0.60). In both unadjusted and covariate-adjusted analyses, DES type was not associated with any differences in ischemic or bleeding complications. Conclusions: As compared with ticagrelor plus aspirin, ticagrelor monotherapy after a short DAPT duration lowered bleeding complications without increasing the ischemic risk, irrespective of DES type. We observed no significant differences among DES-types.