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Ann. Intern. Med., Feb 18 2025, | https://doi.org/10.7326/ANNALS-24-03102
De-escalating Dual Antiplatelet Therapy to Ticagrelor Monotherapy in Acute Coronary Syndrome : A Systemic Review and Individual Patient Data Meta-Analysis of Randomized Clinical Trials
Yong-Joon Lee 1, Xiaofei Gao 2, Sang-Hyup Lee 1, Jing Kan 2, Jun-Jie Zhang 2, Seung-Jun Lee 1, Sung-Jin Hong 1, Chul-Min Ahn 1, Jung-Sun Kim 1, Byeong-Keuk Kim 1, Young-Guk Ko 1, Donghoon Choi 1, Yangsoo Jang 2, Gregg W Stone 3, Shao-Liang Chen 2, Myeong-Ki Hong 1
1Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (Y.-J.L., S.-H.L., S.-J.L., S.-J.H., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.).
2Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (X.G., J.K., J.-J.Z., Y.J., S.-L.C.).
3Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York (G.W.S.).
1Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (Y.-J.L., S.-H.L., S.-J.L., S.-J.H., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.).
2Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (X.G., J.K., J.-J.Z., Y.J., S.-L.C.).
3Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York (G.W.S.).
Drs. Lee and Gao contributed equally to this work.
Corresponding Author: Myeong-Ki Hong, MD, PhD, and Shao-Liang Chen, MD, PhD
Corresponding Author: Myeong-Ki Hong, MD, PhD, and Shao-Liang Chen, MD, PhD
Abstract
Background: The role of transitioning from short dual antiplatelet therapy (DAPT) to potent P2Y12 inhibitor monotherapy in patients with acute coronary syndrome (ACS) undergoing drug-eluting stent (DES) implantation remains inconclusive.
Purpose: To compare the effects of de-escalating DAPT to ticagrelor monotherapy versus standard DAPT from randomized clinical trials in patients with ACS.
Data sources: PubMed, EMBASE, Scopus, and ClinicalTrials.gov from inception to 12 December 2024.
Study selection: Randomized clinical trials comparing de-escalating DAPT to ticagrelor monotherapy versus ticagrelor-based standard DAPT for 12 months, specifically in patients with ACS undergoing DES implantation.
Data extraction: The coprimary end points were an ischemic end point (composite of death, nonprocedural [spontaneous] myocardial infarction, or stroke) and a bleeding end point (Bleeding Academic Research Consortium types 3 or 5 bleeding).
Data synthesis: Individual patient data were obtained from 3 trials (TICO [Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome], T-PASS [Ticagrelor Monotherapy in Patients Treated With New-Generation Drug-Eluting Stents for Acute Coronary Syndrome], and ULTIMATE-DAPT [Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes]), including 9130 randomized patients with ACS; 3132 had ST-segment elevation myocardial infarction (STEMI), 3023 had non-STEMI (NSTEMI), and 2975 had unstable angina. The rate of the primary ischemic end point was not different between the ticagrelor monotherapy and standard DAPT groups (1.7% vs. 2.1%; hazard ratio [HR], 0.85 [95% CI, 0.63 to 1.16]). The rate of the primary bleeding end point was lower in the ticagrelor monotherapy group (0.8% vs. 2.5%; HR, 0.30 [CI, 0.21 to 0.45]). These findings were consistent in patients with STEMI, NSTEMI, and unstable angina.
Limitation: Other de-escalation strategies for modulating antiplatelet therapy were not included.
Conclusion: In patients with ACS undergoing DES implantation, de-escalating DAPT to ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without an increase in ischemic events, regardless of the type of ACS.
Purpose: To compare the effects of de-escalating DAPT to ticagrelor monotherapy versus standard DAPT from randomized clinical trials in patients with ACS.
Data sources: PubMed, EMBASE, Scopus, and ClinicalTrials.gov from inception to 12 December 2024.
Study selection: Randomized clinical trials comparing de-escalating DAPT to ticagrelor monotherapy versus ticagrelor-based standard DAPT for 12 months, specifically in patients with ACS undergoing DES implantation.
Data extraction: The coprimary end points were an ischemic end point (composite of death, nonprocedural [spontaneous] myocardial infarction, or stroke) and a bleeding end point (Bleeding Academic Research Consortium types 3 or 5 bleeding).
Data synthesis: Individual patient data were obtained from 3 trials (TICO [Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome], T-PASS [Ticagrelor Monotherapy in Patients Treated With New-Generation Drug-Eluting Stents for Acute Coronary Syndrome], and ULTIMATE-DAPT [Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes]), including 9130 randomized patients with ACS; 3132 had ST-segment elevation myocardial infarction (STEMI), 3023 had non-STEMI (NSTEMI), and 2975 had unstable angina. The rate of the primary ischemic end point was not different between the ticagrelor monotherapy and standard DAPT groups (1.7% vs. 2.1%; hazard ratio [HR], 0.85 [95% CI, 0.63 to 1.16]). The rate of the primary bleeding end point was lower in the ticagrelor monotherapy group (0.8% vs. 2.5%; HR, 0.30 [CI, 0.21 to 0.45]). These findings were consistent in patients with STEMI, NSTEMI, and unstable angina.
Limitation: Other de-escalation strategies for modulating antiplatelet therapy were not included.
Conclusion: In patients with ACS undergoing DES implantation, de-escalating DAPT to ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without an increase in ischemic events, regardless of the type of ACS.
논문정보
- Review Paper
- 2025년 02월 (BRIC 등록일 2025-02-18)
- 국내(교신)+국외 연구진
- 의약학 > 응용의학
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