Post-MI patients with multi-vessel disease may benefit from long-term P2Y12 inhibitor therapy
Ticagrelor for Secondary Prevention of Atherothrombotic Events in Patients With Multivessel Coronary DiseaseLiterature - Bansilal S, Bonaca MP, Cornel JH, et al. - J Am Coll Cardiol 2018;71:489–96
- Of 21,162 patients randomized in the PEGASUS-TIMI 54 trial, 12,558 (59.4%) had a history of MVD.
- Compared with individuals with single-vessel disease, patients with MVD were at higher risk for MACE (9.37% vs. 8.57%; HRadj: 1.24; 95%CI: 1.03-1.50; P=0.026) and coronary events (7.67% vs. 5.34%; HRadj: 1.49; 95%CI: 1.19-1.87; P=0.0005).
- In MVD patients, compared with placebo, ticagrelor led to significant reductions of MACE (pooled data from the 2 doses tested: 7.94% vs. 9.37%; HR: 0.82; 95%CI: 0.72-0.94; P=0.004), coronary events (6.02% vs. 7.67%; HR: 0.76; 95%CI: 0.66-0.88; P < 0.001), a 36% reduction in coronary death (HR: 0.64; 95%CI: 0.48-0.85; P=0.002), a 21% reduction in MI (HR: 0.79; 95% CI: 0.67 to 0.93), and a 41% reduction in stent thrombosis (HR: 0.59; 95% CI: 0.37 to 0.94).
- Ticagrelor increased the risk of TIMI major bleeding (2.52% vs. 1.08%, HR: 2.67; 95%CI: 1.81-3.93; P<0.001), but not ICH or fatal bleedings.
Patients with a history of MI and MVD had an increased risk for MACE and coronary events compared to those with single-vessel disease. Long-term ticagrelor therapy, on top of aspirin, reduced substantially the risk of MACE in patients with prior MI and MVD and increased the risk of TIMI major bleeding, but not ICH or fatal bleeding. It will be interesting to study the safety and efficacy of ticagrelor monotherapy compared to dual antiplatelet therapy.
In their editorial article, Lee and Tanoue  review data related to the debate regarding the optimal duration of dual antiplatelet therapy (DAPT) post-PCI, and note that the results reported by Bansilal et al. support a higher intensity and extended duration of antiplatelet therapy in post-MI patients with multi-vessel coronary artery disease. The authors are intrigued by this approach of higher intensity and extended duration of DAPT as opposed to revisiting revascularization strategies to manage MVD patients. Although the pathophysiology mechanism for the increased risk of coronary events and death post-MI in MVD patients is unknown, it is clear that these patients benefit from ticagrelor therapy. The authors conclude: ‘Taken together, the PEGASUS-TIMI 54 subset analyses give validation to existing data supporting improved outcomes with higher intensity and longer duration of antiplatelet therapy with ticagrelor in certain high-risk patient cohorts. Specifically, the data support that the presence of MVD may be an indication to pursue extended DAPT with ticagrelor for up to 3 years in the absence of limiting adverse effects.’