Korean Circ J.  2022 Apr;52(4):324-337. 10.4070/kcj.2021.0321.

Ticagrelor Monotherapy After 3-Month Dual Antiplatelet Therapy in Acute Coronary Syndrome by High Bleeding Risk: The Subanalysis From the TICO Trial

Affiliations
  • 1Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
  • 2Division of Cardiology, Department of Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
  • 3Division of Cardiology, Wonkwang University Hospital, Iksan, Korea
  • 4Division of Cardiology, Kangwon National University School of Medicine, Chuncheon, Korea
  • 5Division of Cardiology, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
  • 6Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
  • 7Division of Cardiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
  • 8Division of Cardiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
  • 9Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
  • 10Department of Preventive Medicine and Biostatistics, Yonsei University College of Medicine, Seoul, Korea
  • 11Division of Cardiology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, Korea

Abstract

Background and Objectives
Identifying patients with high bleeding risk (HBR) is important when making decisions for antiplatelet therapy strategy. This study evaluated the impact of ticagrelor monotherapy after 3-month dual antiplatelet therapy (DAPT) according to HBR in acute coronary syndrome (ACS) patients treated with drug eluting stents (DESs).
Methods
In this post-hoc analysis of the TICO trial, HBR was defined by 2 approaches: meeting Academic Research Consortium for HBR (ARC-HBR) criteria or Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent DAPT (PRECISEDAPT) score ≥25. The primary outcome was a 3–12 months net adverse clinical event (composite of major bleeding and adverse cardiac and cerebrovascular events).
Results
Of the 2,980 patients without adverse events during the first 3 months after DES implantation, 453 (15.2%) were HBR by ARC-HBR criteria and 504 (16.9%) were HBR by PRECISE-DAPT score. The primary outcome rate was higher in HBR versus non-HBR patients (by ARC-HBR criteria: hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.76– 4.69; p<0.001; by PRECISE-DAPT score: HR, 3.09; 95% CI, 1.92–4.98; p<0.001). Ticagrelor monotherapy after 3-month DAPT was associated with lower primary outcome rate than ticagrelor-based 12-month DAPT regardless of HBR by ARC-HBR criteria, with similar magnitudes of therapy effect for HBR and non-HBR patients (p-interaction=0.400). Results were consistent by PRECISE-DAPT score (p-interaction=0.178).
Conclusions
In ACS patients treated with DESs, ticagrelor monotherapy after 3-month DAPT was associated with lower rate of adverse clinical outcomes regardless of HBR, with similar magnitudes of therapy effect between HBR and non-HBR. Trial Registration: ClinicalTrials.gov Identifier: NCT02494895

Keyword

Acute coronary syndrome; Ticagrelor; Hemorrhage

Figure

  • Figure 1 Distribution of TICO patients by HBR. Study patients were classified by HBR in 2 different approaches: 1) by meeting ARC-HBR criteria (at least 1 major or 2 minor criteria were met) or 2) by PRECISE-DAPT score for HBR (score ≥25).ARC-HBR = Academic Research Consortium for High Bleeding Risk; HBR = high bleeding risk; PRECISE-DAPT = Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy.

  • Figure 2 Time-to-event curves for clinical events by HBR. NACE (A, D), major bleeding (B, E), and MACCEs (C, F).ARC-HBR = Academic Research Consortium for High Bleeding Risk; CI = confidence interval; HBR = high bleeding risk; HR = hazard ratio; MACCE = major adverse cardiac and cerebrovascular event; NACE = net adverse clinical event; PCI = percutaneous coronary intervention; PRECISE-DAPT = Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy.

  • Figure 3 Time-to-event curves for clinical events by HBR and antiplatelet therapy strategy. NACE (A, D), major bleeding (B, E), and MACCEs (C, F).ARC-HBR = Academic Research Consortium for High Bleeding Risk; CI = confidence interval; HBR = high bleeding risk; HR = hazard ratio; MACCE = major adverse cardiac and cerebrovascular event; NACE = net adverse clinical event; PCI = percutaneous coronary intervention; PRECISE-DAPT = Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy.


Cited by  1 articles

Balancing Between Ischemic and Bleeding Risk in PCI Patients With ‘Bi-Risk’
Mahn-Won Park
Korean Circ J. 2022;52(4):338-340.    doi: 10.4070/kcj.2021.0429.


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