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