Physicians' Academy for Cardiovascular Education

Switching to P2Y12 monotherapy after DAPT lowers bleeding risk in high-risk NSTE-ACS patients

News - Nov. 18, 2019

Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention for Acute Coronary Syndrome

Presented during the AHA Scientific Sessions 2019 by Usman Baber (Icahn Sch of Med at Mount Sinai, New York, NY).

Introduction and methods

The prevailing construct of dual antiplatelet therapy (DAPT) as the preferred treatment for patients with acute coronary syndromes (ACS) originated from clinical trials showing that the addition of an oral P2Y12 inhibitor to aspirin significantly lowers recurrent ischemic events as compared with aspirin alone. The benefits, or harms, of maintaining aspirin as a long-term component of DAPT in the setting of ACS remains unknown, however, as aspirin served as a background agent in earlier studies.

Recent studies have suggested that aspirin-free strategies lower bleeding without increasing ischemic risk as compared with conventional DAPT in select patients undergoing percutaneous coronary intervention (PCI).

The TWILIGHT-ACS study set out to examine the effect of antiplatelet monotherapy with ticagrelor alone versus ticagrelor plus aspirin among patients with non-ST elevation acute coronary syndromes (NSTE-ACS) undergoing PCI with drug eluting stents (DES) who had already completed a 3-month course of DAPT. It was a randomized, double-blind placebo-controlled trial, in which high-risk patients underwent PCI and were treated with ticagrelor plus aspirin for three months. Event-free and adherent patients were then randomized to aspirin vs. placebo and continued ticagrelor for an additional year. After this period, they continued on standard of care for a 3 month observation period. 4614 Patients were randomized, 2494 of whom had unstable angina (UA) and 2120 of whom had NSTEMI. Primary endpoint was BARC 2, 3 or 5 bleeding between 0 - 12 months after randomization.

Main results


Among patients with NSTE-ACS undergoing PCI with DES and who have completed a 3-month course of DAPT with ticagrelor plus aspirin, continued treatment with ticagrelor alone significantly lowers clinically relevant and major bleeding without increasing risk for ischemic events over one year. The effect of ticagrelor monotherapy with respect to bleeding and ischemic events was found to be uniform across different levels of risk.

Generalizing to a broader population of PCI patients without high-risk features pre-specified in TWILIGHT is limited and findings do not apply to patients with STEMI.

- Our reporting is based on the information provided during AHA Scientific Sessions 2019 -

Watch a video on this study by Usman Baber

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