scholarly journals Walking the Line with Ticagrelor: Meta-Analysis Comparing the Safety and Efficacy of Ticagrelor Monotherapy after a Short Course of Ticagrelor-Based Dual Antiplatelet Therapy versus Standard Therapy in Complex Percutaneous Coronary Intervention

2021 ◽  
Vol 10 (23) ◽  
pp. 5506
Author(s):  
Francesco Condello ◽  
Matteo Sturla ◽  
Riccardo Terzi ◽  
Alberto Polimeni ◽  
Giulio G. Stefanini
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Cardiovascular Death ◽  
Pooled Analysis ◽  
Bleeding Events ◽  
Short Course ◽  
Percutaneous Coronary

(1) Shorter-duration dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy has been shown to significantly reduce bleeding events while preserving anti-ischemic effects in patients undergoing conventional percutaneous coronary interventions (PCI). Whether this strategy is also safe and effective in complex PCI remains elusive; (2) A systematic search of randomized controlled trials comparing a short course of ticagrelor-based DAPT versus standard DAPT in patients undergoing complex PCI was performed; (3) Of 10,689 studies screened, 3 were identified for a total of 4176 participants on ticagrelor monotherapy after a short course of ticagrelor-based DAPT, and 4209 on standard DAPT. The pooled analysis revealed no difference in the outcomes of major bleeding, myocardial infarction, definite or probable stent thrombosis and ischemic stroke. A significant reduction in the risk of cardiovascular death (incidence rate ratio (IRR) 0.52; 95% CI 0.28–0.96; p = 0.04), all-cause death (IRR 0.65; 95% CI 0.49–0.86; p = 0.003), and any bleeding events (IRR 0.62; 95% CI 0.47–0.81; p < 0.001) was seen in the shorter DAPT group; (4) Among patients undergoing complex PCI, ticagrelor monotherapy after a short course of ticagrelor-based DAPT significantly reduced bleeding risk without increasing ischemic risk. More data are needed to definitively explain mortality benefits.

scholarly journals 745 Meta-analysis comparing the safety and efficacy of ticagrelor monotherapy after a short course of ticagrelor-based dual antiplatelet therapy versus standard therapy in complex percutaneous coronary interventions

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Francesco Condello ◽  
Matteo Sturla ◽  
Riccardo Terzi ◽  
Alberto Polimeni ◽  
Giulio Stefanini
Keyword(s):  
Antiplatelet Therapy ◽  
Major Bleeding ◽  
Dual Antiplatelet Therapy ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Minor Bleeding ◽  
Bleeding Events ◽  
Short Course ◽  
Percutaneous Coronary ◽  
Significant Difference

Abstract Aims Current guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor for 6–12 months after percutaneous coronary intervention (PCI). A shorter duration ticagrelor-based DAPT followed by ticagrelor monotherapy can significantly reduce bleeding events while preserving anti-ischaemic effects in patients undergoing conventional PCI. Whether this strategy can be safely and effectively applied to those patient that undergo ‘complex’ PCI is uncertain. Methods We performed a systematic search of randomized controlled trials comparing a short course of ticagrelor-based DAPT vs. standard DAPT in patients undergoing complex PCI. A mixed-effects Poisson regression model with random intervention effects was used to estimate the pooled incidence rate ratios (IRR) with 95% confidence intervals (CI). Results Out of 10 689 studies screened, three were identified for a total of 4176 participants on ticagrelor monotherapy after a short course of ticagrelor based DAPT, and 4209 on standard DAPT. Overall, the pooled analysis showed a strong evidence that compared to standard treatment, ticagrelor monotherapy after a short course of ticagrelor-based DAPT (1–3 months) reduced the risk of cardiovascular death [IRR 0.52; CI (0.28–0.96); P = 0.04; I2 = 0%], all-cause death [IRR 0.65; CI (0.49–0.86); P = 0.003; I2 = 0%], and any bleeding events [IRR 0.62; CI (0.47–0.81); P &lt; 0.001; I2 = 44%]. Weak evidence was found of an association between the experimental strategy and a lower risk of myocardial infarction [IRR 0.79; CI (0.61–1.01); P = 0.06; I2 = 0%]. Instead, no significant difference in the risk of major bleeding [IRR 0.72; CI (0.48–1.08); P = 0.11; I2 = 61%], definite or probable stent thrombosis [IRR 0.77; CI (0.34–1.75); P = 0.53; I2 = 0%] and ischaemic stroke [IRR 0.83; CI (0.25–2.73); P = 0.76; I2 = 0%] was observed. We speculate that the observed mortality benefits might be related to the reduction of any bleeding events, mainly dictated by minor bleeding reduction, since major bleeding did not seem to be decreased in the shorter regimen group. Conclusion Among patients undergoing complex PCI, ticagrelor monotherapy after a short course of ticagrelor-based DAPT significantly reduced bleeding risk without increasing ischaemic risk. As complex PCI procedures are being increasingly performed nowadays, and more comorbid patients are being treated, more studies are required to confirm and explain these findings. This could lead to optimization of antiplatelet therapy across a broad spectrum of patients.

TWILIGHT: A Randomized Trial of Ticagrelor Monotherapy Versus Ticagrelor Plus Aspirin Beginning at 3 Months in High-risk Patients Undergoing Percutaneous Coronary Intervention

2020 ◽  
Vol 14 ◽  
Author(s):  
Johny Nicolas ◽  
Usman Baber ◽  
Roxana Mehran
Keyword(s):  
Percutaneous Coronary Intervention ◽  
High Risk ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Coronary Intervention ◽  
Bleeding Events ◽  
High Risk Patients ◽  
Risk Of Death ◽  
Percutaneous Coronary ◽  
Risk Patients

A P2Y12 inhibitor-based monotherapy after a short period of dual antiplatelet therapy is emerging as a plausible strategy to decrease bleeding events in high-risk patients receiving dual antiplatelet therapy after percutaneous coronary intervention. Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention (TWILIGHT), a randomized double-blind trial, tested this approach by dropping aspirin at 3 months and continuing with ticagrelor monotherapy for an additional 12 months. The study enrolled 9,006 patients, of whom 7,119 who tolerated 3 months of dual antiplatelet therapy were randomized after 3 months into two arms: ticagrelor plus placebo and ticagrelor plus aspirin. The primary endpoint of interest, Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, occurred less frequently in the experimental arm (HR 0.56; 95% CI [0.45–0.68]; p<0.001), whereas the secondary endpoint of ischemic events was similar between the two arms (HR 0.99; 95% CI [0.78–1.25]). Transition from dual antiplatelet therapy consisting of ticagrelor plus aspirin to ticagrelor-based monotherapy in high-risk patients at 3 months after percutaneous coronary intervention resulted in a lower risk of bleeding events without an increase in risk of death, MI, or stroke.

Abstract 15440: Bleeding Complications May Outweigh the Risk of Thrombosis in Patients With End-stage Liver Disease Taking Dual Antiplatelet Therapy After Percutaneous Coronary Intervention

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sami J Natour ◽  
May Myint Thanda Kyaw ◽  
Ronald W Busuttil ◽  
Jonathan M Tobis ◽  
Henry M Honda
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Coronary Intervention ◽  
Bleeding Complications ◽  
Bleeding Events ◽  
Stent Restenosis ◽  
Percutaneous Coronary ◽  
Ischemic Complications ◽  
End Stage

Introduction: Randomized trials have demonstrated the safety and efficacy of one month of dual antiplatelet therapy (DAPT) after placement of drug-eluting stents in patients with high bleeding risk. Patients with end-stage liver disease (ESLD) are underrepresented in these trials. Patients who undergo percutaneous coronary intervention (PCI) in preparation for orthotopic liver transplantation (OLT) exhibit a high incidence of bleeding complications on DAPT. The rates of bleeding versus thrombotic complications in ESLD patients placed on DAPT following PCI are poorly described. Methods: We retrospectively collected data from 61 patients who were evaluated for OLT between 2016 and 2019 and underwent PCI prior to listing. Bleeding events were classified using the Bleeding Academic Research Consortium (BARC) definitions and included if the following criteria were met: events occurred in the setting of DAPT, were non-procedural in etiology, and occurred during the time following PCI and prior to OLT. Ischemic complications were evaluated by the incidence of myocardial infarction (MI), stent thrombosis, in-stent restenosis (>50%) and all-cause mortality at 1 year follow-up. Results: A total of 55/61 patients (90%) were placed on DAPT following PCI. Among them, 21/55 patients (38%) bled while taking DAPT, including 15 patients (27%) with BARC types 3-5 first-time bleeding events and 10 patients (18%) requiring early discontinuation of therapy. The median time to first bleeding event was 8 days (range 1 to 477 days, 85 th percentile 17 days). Among ischemic complications, MI occurred in 11/55 patients (20%) however only one patient had a type 1 MI with the remaining being type 2 in etiology. There were no episodes of stent thrombosis and 2 episodes of in-stent restenosis during the 1 year follow-up. A total of 12/55 patients (22%) went on to receive OLT and 18/55 (33%) passed away by 1 year post-PCI. Conclusions: Patients with ESLD exhibit a high rate of clinically significant bleeding on DAPT when compared to overall thrombotic events. The majority of bleeds occurred within the first month after PCI. These findings illustrate the need for larger studies to assess the safety of single instead of dual antiplatelet therapy in patients with ESLD who receive PCI.

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