Mauro Gitto; Usman Baber; Samantha Sartori; Birgit Vogel; Dominick Angiolillo; Carlo Briguori; David Cohen; Timothy Collier; Dariusz Dudek; Angelo Oliva; Javier Escaned; Yihan Feng; C. Gibson; Ya-ling Han; Francesca Di Muro; Richard Shlofmitz; Kurt Huber; Philippe Steg; Samin Sharma; Gennaro Sardella; Adnan Kastrati; Upendra Kaul; Ran Kornowski; Vijay Kunadian; Giulio Stefanini; Shamir Mehta; George Dangas; Roxana Mehran

doi:10.4244/EIJ-D-24-00973

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Original Research

DOI: 10.4244/EIJ-D-24-00973

Ticagrelor monotherapy versus ticagrelor plus aspirin in patients with chronic coronary syndrome and high ischaemic risk: a post hoc analysis of the TWILIGHT trial

Mauro Gitto¹^,², MD; Usman Baber³, MD; Samantha Sartori¹, PhD; Birgit Vogel¹, MD; Dominick J. Angiolillo⁴, MD, PhD; Carlo Briguori⁵, MD, PhD; David J. Cohen⁶^,⁷, MD, MSc; Timothy Collier⁸, MSc; Dariusz Dudek⁹, MD, PhD; Angelo Oliva¹^,², MD; Javier Escaned¹⁰, MD, PhD; Yihan Feng¹, MS; C. Michael Gibson¹¹, MD, MSc; Ya-Ling Han¹², MD, PhD; Francesca Maria Di Muro¹, MD; Richard A. Shlofmitz⁷, MD; Kurt Huber¹³^,¹⁴, MD; Philippe Gabriel Steg¹⁵, MD; Samin Sharma¹, MD; Gennaro Sardella¹⁶, MD; Adnan Kastrati¹⁷, MD; Upendra Kaul¹⁸, MD; Ran Kornowski¹⁹, MD; Vijay Kunadian²⁰^,²¹, MBBS, MD; Giulio G. Stefanini²²^,², MD, PhD; Shamir R. Mehta²³, MD; George Dangas¹, MD; Roxana Mehran¹, MD

Abstract

Background: Short dual antiplatelet therapy (DAPT) followed by ticagrelor monotherapy may be a valuable therapeutic option for patients with chronic coronary syndrome (CCS) and high ischaemic risk (HIR) undergoing percutaneous coronary intervention (PCI).

Aims: We aimed to compare ticagrelor monotherapy with ticagrelor-based DAPT in CCS patients with and without HIR undergoing PCI.

Methods: The present analysis included the CCS cohort of the TWILIGHT trial, which randomised PCI patients to ticagrelor alone or in combination with aspirin for 12 months after 3 months of ticagrelor-based DAPT. Patients were stratified into HIR and non-HIR based on the 2019 European Society of Cardiology (ESC) CCS guidelines definition. Outcomes of interest were major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction or stroke, and Bleeding Academic Research Consortium (BARC) Type 2-5 bleeding at 1 year.

Results: Of the 2,503 CCS patients who underwent randomisation, the ESC definition classified 1,264 (50.5%) as HIR and 1,239 (49.5%) as non-HIR. HIR patients displayed a higher risk of MACCE (3.9% vs 2.3%; p=0.015) and similar rates of BARC Type 2-5 bleeding (5.1% vs 5.7%; p=0.455) as compared to non-HIR patients. Ticagrelor monotherapy and ticagrelor-based DAPT were associated with similar risks of MACCE (HIR: 4.0% vs 3.8%, hazard ratio [HR] 1.06, 95% confidence interval [CI]: 0.60-1.85; non-HIR: 2.1% vs 2.6%, HR 0.80, 95% CI: 0.38-1.66, p_interaction=0.553) and bleeding (HIR: 4.7% vs 5.7%, HR 0.82, 95% CI: 0.50-1.33; non-HIR: 4.9% vs 6.7%, HR 0.71, 95% CI: 0.44-1.14; p_interaction=0.684) in both the HIR and non-HIR groups.

Conclusions: In a post hoc analysis of the TWILIGHT trial that included CCS patients undergoing PCI, ticagrelor monotherapy after 3 months of DAPT appeared to be safe and was not associated with increased risks of ischaemic or bleeding events, regardless of baseline HIR status, compared with standard ticagrelor-based DAPT. These findings suggest the potential to expand guideline recommendations for ticagrelor monotherapy in CCS.

Forgot your password?

No account yet?
Sign up for free!

Create my pcr account

Join us for free and access thousands of articles from EuroIntervention, as well as presentations, videos, cases from PCRonline.com