Coronary interventions

Ticagrelor with and without aspirin in patients with a prior coronary artery bypass graft undergoing percutaneous coronary intervention: the TWILIGHT-CABG study

EuroIntervention 2022;18:e897-e909. DOI: 10.4244/EIJ-D-22-00319

Gennaro Sardella
Gennaro Sardella1, MD; Frans J. Beerkens2, MD; George Dangas2, MD, PhD; Davide Cao2,3, MD; Usman Baber4, MD, MS; Samantha Sartori2, PhD; David J. Cohen5,6, MD, MSc; Carlo Briguori7, MD, PhD; Robert Gil8, MD, PhD; Johny Nicolas2, MD; Zhongjie Zhang2, MPH; Dariusz Dudek8, MD, PhD; Vijay Kunadian9, MD, BS, MB; Ran Kornowski10, MD; Giora Weisz11, MD; Bimmer Claessen12, MD, PhD; Steven Marx11, MD; Javier Escaned13, MD, PhD; Kurt Huber14, MD; Timothy Collier15, MSc; David J. Moliterno16, MD; E. Magnus Ohman17, MD; Mitchell W. Krucoff17, MD; Adnan Kastrati18, MD; Phillipe Gabriel Steg, MD; Dominick J. Angiolillo19, MD, PhD; Shamir Mehta20, MD; Richard Shlofmitz5, MD; Samin Sharma2, MD; Stuart Pocock15, PhD; Charles Michael Gibson21, MD; Roxana Mehran2, MD
1. Department of Cardiology, Policlinico Umberto I University, Rome, Italy; 2. The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 3. Cardio Center, Humanitas Research Hospital IRCCS, Milan, Italy; 4. Cardiovascular Disease Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; 5. Department of Cardiology, St. Francis Hospital & Heart Center, Roslyn, NY, USA; 6. Cardiovascular Research Foundation, New York, NY, USA; 7. Mediterranea Cardiocentro, Naples, Italy; 8. Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland; 9. 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; 10. Cardiology Department, Rabin Medical Center, Petah Tikva, Israel; 11. Division of Cardiology, Department of Medicine, Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, NY, USA; 12. Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands; 13. Hospital Clínico San Carlos IdISCC, Complutense University of Madrid, Madrid, Spain; 14. 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria and Sigmund Freud University, Medical Faculty, Vienna, Austria; 15. Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom; 16. University of Kentucky, Lexington, KY, USA; 17. Duke University Medical Center-Duke Clinical Research Institute, Durham, NC, USA; 18. Department of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany; 19. Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL , USA; 20. Department of Cardiology, Hamilton Health Sciences, Hamilton, ON, Canada; 21. Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA

Background: Prior coronary artery bypass graft surgery (CABG) patients undergoing percutaneous coronary intervention (PCI) are often older and present with multiple comorbidities. Ticagrelor monotherapy after a short course of dual antiplatelet therapy (DAPT) has emerged as an effective bleeding-avoidance strategy among high-risk patients.

Aims: We aimed to examine the effects of ticagrelor with or without aspirin in prior CABG patients undergoing PCI within the TWILIGHT trial.

Methods: After 3 months of ticagrelor plus aspirin, patients were randomised to either aspirin or placebo, in addition to ticagrelor, for 12 months and compared by prior CABG status. The primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding. The key secondary endpoint was all-cause death, myocardial infarction (MI), or stroke.

Results: Out of 7,119 patients, a total of 703 (10.8%) patients had prior CABG within the randomised cohort. Prior CABG patients had more comorbidities and a higher incidence of BARC type 2, 3, or 5 bleeding and death, MI or stroke at 1 year after randomisation, compared with patients without prior CABG. Ticagrelor monotherapy was associated with significantly less BARC 2, 3, or 5 bleeding among prior CABG patients compared with DAPT (4.9% vs 9.6%, hazard ratio [HR] 0.50, 95% confidence interval [CI]: 0.28 to 0.90; pinteraction=0.676) and similar rates of death, MI or stroke (10.0% vs 8.7%, HR 1.14, 95% CI: 0.70 to 1.87; pinteraction=0.484). When comparing target vessel type, treatment effects were consistent among graft- and native-vessel interventions.

Conclusions: In high-risk patients with prior CABG, ticagrelor monotherapy reduced bleeding without compromising ischaemic outcomes compared with ticagrelor plus aspirin.

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