In a nutshell: The hottest developments in the field of cardiology in 2020. Section 5. Coronary artery disease
3. TICO (Ticagrelor With or Without Aspirin in Acute Coronary Syndrome After Percutaneous Coronary Intervention) trial
Ticagrelor monotherapy after 3 months of DAPT was superior at preventing ischemia and bleeding after PCI for ACS.
Patients undergoing PCI for ACS were randomized to ticagrelor monotherapy after 3 months of DAPT versus standard therapy.
Among ACS patients who underwent PCI with an ultrathin biodegradable-polymer sirolimus-eluting stent, ticagrelor monotherapy after 3 months of DAPT was superior to standard therapy of DAPT for 12 months. Ticagrelor monotherapy was effective at preventing net composite ischemic and bleeding events.
Ticagrelor monotherapy appears to be an emerging strategy, especially for patients with increased bleeding risk, after a short duration of DAPT.
Unlike TWILIGHT trial, TICO included patients with STEMI also and hence widens the spectrum of ticagrelor montherapy use in acute coronary syndrome setting.
Taken together, the observations from TICO-STEMI appear to further highlight the need for optimal distinction between the risk factors of bleeding and ischemia in post-PCI patients. This is not an easy endeavour given the documented overlap between the two. However, it is a goal worth pursuing, as a proper stratification tool may have the capacity to improve prognosis given that both thrombotic and bleeding events are associated with increased mortality.
Source: JAMA cardiology: Kim B, Hong S, Cho Y, et al. The TICO Randomized Clinical Trial. JAMA. 2020;323(23):2407–2416. doi:10.1001/jama.2020.7580
4. TWILIGHT-COMPLEX (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) Substudy
Subgroups from TWILIGHT trial were analysed separately- NSTEMI, Diabetics, complex PCI cases.
TWILIGHT trial had earlier shown that short-duration DAPT (3 months) followed by ticagrelor monotherapy for 12 months results in less bleeding compared with longer-duration DAPT (additional 12 months) among patients undergoing PCI with a DES and at high ischemic or bleeding risk.
These results were maintained even among the subgroup of patients presenting with NSTE-ACS, diabetes mellitus, and those undergoing complex PCI in the TWILIGHT-COMPLEX substudy.
These are interesting findings, and help advance our understanding of the optimal duration and type of antiplatelet agent post-PCI.
Similar findings were noted with clopidogrel in the SMART-CHOICE and STOPDAPT-2 trials. These trials are thus likely to influence future guidelines regarding DAPT duration post-PCI.
Source: JACC: Angiolillo DJ, Baber U, Sartori S, et al. Ticagrelor With or Without Aspirin in High-Risk Patients With Diabetes Mellitus Undergoing Percutaneous Coronary Intervention. J Am Coll Cardiol 2020;Mar 30
Coronary artery disease (CAD) management id undoubtedly the most impactful arena of interventional cardiology. This year we witnessed several important trials that redefined the drug management as well as interventions for CAD. There was ATPCI trial that explored the benefit of trimetazidine in post PCI setup, Tailor PCI, TICO, TWILIGHT COMPLEX, ALPHEUS and COMPARE CRUSH trials will serve as landmarks for future guidelines for antiplatelet therapy in CAD.
The extended outcome of PRECOMBAT trial sheds more light on ever-debatable CABG vs. PCI for left main disease while DEFINITION II has supported DK crush for complex PCI lesions. Finally, COMPARE ACUTE supported the role of FFR in complete revascularisation during the index procedure in STEMI setting.
Page 1: ATPCI and TAILOR-PCI trials
Page 2. TICO and TWILIGHT COMPLEX trials
Page 3. ALPHEUS and COMPARE-CRUSH trials
Page 4. HOST REDUCE POLYTECH ACS and PRECOMBAT trials
Page 5. DEFINITION II, COMPARE ACUTE and ONTIME 3 trials
Long term trimetazidine is safe but not preventative of angina or adverse outcome after PCI.
The ATPCI trial followed 6007 patients receiving either trimetazidine or a placebo, following successful percutaneous coronary intervention (PCI). After a median follow-up of 47.5 months, trimetazidine did not improve either the outcome or the occurrence of angina.
The event rate in this trial was lower than expected and may have contributed to the null finding.
"It is the first study to test the value of increasing the energy status of the ischemic myocyte with trimetazidine in terms of hard end points such as cardiac death and hospitalization. This is particularly relevant considering that a recent study with ranolazine (RIVER-PCI trial), another piperazine derivative, in a similar patient setting failed to show a benefit" noted Roberto Ferrari, MD Department of Cardiology and LTTA Centre University Hospital of Ferrara ITALY (study author).
Source: The Lancet Journal: Ferrari R, Ford I, Fox K, et al. Efficacy and safety of trimetazidine after percutaneous coronary intervention (ATPCI): Lancet 2020;396:830-8.
2. The Tailor PCI (Tailored Antiplatelet Initiation to Lessen Outcomes due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention) trial
A genotype-guided strategy was not superior at reducing adverse cardiovascular events compared with standard therapy after PCI.
Patients undergoing primary PCI for stable or unstable coronary artery disease were randomized to a genotype-guided strategy (n = 2,652) versus standard therapy (n = 2,650).
The primary analysis was between 903 subjects with a loss of function allele (*2 or *3) in the genotype-guided group compared with 946 subjects in the standard therapy group with a loss of function allele.
Among patients who underwent PCI for stable or unstable coronary artery disease, a genotype-guided strategy was not beneficial compared to standard therapy. The primary outcome of major adverse cardiovascular events and bleeding were similar between treatment groups at 12 months.
"Although these results fell short of the effect size that we predicted, they nevertheless provide a signal that offers support for the benefit of genetically guided therapy, with approximately one-third fewer adverse events in the patients who received genetically guided treatment compared with those who did not," said Naveen L. Pereira, MD, of Mayo Clinic, Rochester, Minnesota, co-principal investigator of the study, who presented the results.
Source: JAMA cardiology: Pereira NL, Farkouh ME, So D, et al. The TAILOR-PCI Randomized Clinical Trial. JAMA 2020;324:761-71
Disclaimer: This site is primarily intended for healthcare professionals. Any content/information on this website does not replace the advice of medical and/or health professionals and should not be construed as medical/diagnostic advice/endorsement/treatment or prescription. Use of this site is subject to our terms of use, privacy policy, advertisement policy. © 2024 Minerva Medical Treatment Pvt Ltd