Ticagrelor alone better than with aspirin in reducing bleeding after complex PCI

Continuation of ticagrelor monotherapy results in a lower incidence of bleeding without increasing the risk of ischaemic events than that of the combined ticagrelor plus aspirin therapy among patients undergoing percutaneous coronary intervention (PCI) who initially completed 3 months of ticagrelor plus aspirin, according to a study.

The investigators assessed the effect of ticagrelor monotherapy vs ticagrelor plus aspirin in patients undergoing complex PCI from TWILIGHT*, a randomized, double-blind, placebo-controlled trial.

Event-free and adherent patients in the TWILIGHT trial maintained their ticagrelor treatment and were randomized to receive aspirin or placebo for 1 year after 3 months of ticagrelor plus aspirin. Bleeding and ischaemic events were evaluated at 1 year after randomization.

Complex PCI referred to any of the following: three vessels treated, three or more lesions treated, total stent length >60 mm, bifurcation with two stents implanted, atherectomy device use, left main PCI, surgical bypass graft or chronic total occlusion as target lesions.

Of the 7,119 patients included in the main trial, 2,342 underwent complex PCI. Ticagrelor plus placebo was associated with a significantly lower rate of Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding compared to ticagrelor plus aspirin (4.2 percent vs 7.7 percent; hazard ratio [HR], 0.54, 95 percent confidence interval [CI], 0.38–0.76). Patients on continuing ticagrelor monotherapy also had reduced BARC type 3 or 5 bleeding (1.1 percent vs 2.6 percent; HR, 0.41, 95 percent CI, 0.21–0.80).

No significant between-group differences were seen in terms of death, myocardial infarction or stroke (3.8 percent vs 4.9 percent; HR, 0.77, 95 percent CI, 0.52–1.15), nor in stent thrombosis.

*Ticagrelor with Aspirin or Alone in High-Risk Patients after Coronary Intervention