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

DOI: 10.4244/EIJ-D-21-00721

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.

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