DAPT de-escalation strategy suitable for stabilized MI patients with high ischemic risk: JAMA

In the post hoc analysis of the TALOS-AMI randomized clinical trial, 1371 patients (50.8%) were categorized as having high ischemic risk. The researchers revealed that compared with ticagrelor-based dual antiplatelet therapy (DAPT), the bleeding and ischemic outcomes of an unguided de-escalation strategy were consistent, irrespective of high ischemic risk features, with no heterogeneity. TALOS-AMI is an open-label, assessor-blinded, multicenter, randomized clinical trial.

In patients with acute MI who have high ischemic risk, there is a lack of data on the safety and efficacy of the de-escalation strategy of switching from ticagrelor to clopidogrel. To fill this knowledge, Myunhee Lee, The Catholic University of Korea, Seoul, Republic of Korea, and colleagues aimed to evaluate the outcomes of the de-escalation strategy compared with DAPT with ticagrelor in stabilized patients with AMI and high ischemic risk following percutaneous coronary intervention (PCI).

The study included patients (mean age, 60.0 years; 16.8% female) with acute myocardial infarction (AMI) who had no event during 1 month of ticagrelor-based DAPT after PCI. Patients were randomly assigned to de-escalation from ticagrelor to clopidogrel or ticagrelor-based DAPT.

High ischemic risk was defined as having a history of chronic kidney disease or diabetes, at least 3 lesions treated, multivessel PCI, at least 3 stents implanted, total stent length greater than 60 mm, left main PCI, or bifurcation PCI with at least 2 stents.

The outcomes included ischemic outcomes (composite of cardiovascular death, ischemic stroke, myocardial infarction, stent thrombosis, or ischemia-driven revascularization) and bleeding outcomes (Bleeding Academic Research Consortium [BARC] type 2, 3, or 5 bleeding).

The study led to the following findings:

• Of 2697 patients with AMI, 1371 (50.8%; 684 assigned to de-escalation and 687 assigned to ticagrelor-based DAPT) had high ischemic risk features and a significantly higher risk of ischemic outcomes than those without high ischemic risk (1326 patients [49.2%], including 665 assigned to de-escalation and 661 assigned to ticagrelor-based DAPT) (hazard ratio [HR], 1.74).
• De-escalation to clopidogrel, compared with ticagrelor-based DAPT, showed no significant difference in ischemic risk across the high ischemic risk group (HR, 0.88) and the non–high ischemic risk group (HR, 0.65), without heterogeneity.
• The bleeding risk of the de-escalation group was consistent in both the high ischemic risk group (HR, 0.64) and the non–high ischemic risk group (HR, 0.42), without heterogeneity.

"The findings suggest that in stabilized patients with acute MI, the bleeding and ischemic outcomes of an unguided de-escalation strategy with clopidogrel compared with a ticagrelor-based DAPT strategy were consistent without significant interaction, irrespective of the presence of high ischemic risk," the researchers wrote.

Reference:

Lee M, Byun S, Lim S, et al. Dual Antiplatelet Therapy De-Escalation in Stabilized Myocardial Infarction With High Ischemic Risk: Post Hoc Analysis of the TALOS-AMI Randomized Clinical Trial. JAMA Cardiol. Published online December 20, 2023. doi:10.1001/jamacardio.2023.4587