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

• Lee YJ
• Suh Y
• Kim JS
• Cho YH
• Yun KH
• Kim YH
• Cho JY
• Her AY
• Cho S
• Jeon DW
• Yoo SY
• Cho DK
• Hong BK
• Kwon H
• Hong SJ
• Ahn CM
• Shin DH
• Nam CM
• Kim BK
• Ko YG
• Choi D
• Hong MK
• Jang Y
• for the TICO investigators

• KMID: 2528027
• DOI: http://doi.org/10.4070/kcj.2021.0321

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.

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