Timing of Platelet Inhibition After Acute Coronary Syndrome - TOPIC

Contribution To Literature:

The TOPIC trial showed that de-escalation of long-term antiplatelet therapy with aspirin/clopidogrel was superior at preventing net ischemic events.

Description:

The goal of the trial was to evaluate long-term treatment with aspirin/clopidogrel (switched dual antiplatelet therapy [DAPT]) compared with aspirin/newer ADP antagonist (unchanged DAPT) after 1 month of initial treatment with aspirin/newer ADP antagonist for an acute coronary syndrome.

Study Design

  • Randomized
  • Parallel

Patients who were event free after an acute coronary syndrome and initially treated with 1 month of aspirin/newer ADP antagonist were randomized to aspirin/clopidogrel (switched DAPT; n = 323) versus aspirin/newer ADP antagonist (unchanged DAPT; n = 323).

  • Total number of enrollees: 646
  • Duration of follow-up: 1 year
  • Mean patient age: 60 years
  • Percentage female: 18%
  • Percentage with diabetes: 27%

Inclusion criteria:

  • Event free after an acute coronary syndrome and initially treated with 1 month of aspirin/newer ADP antagonist

Exclusion criteria:

  • Intracranial hemorrhage
  • Contraindication to aspirin, clopidogrel, prasugrel, or ticagrelor
  • Thrombocytopenia
  • Major bleeding in the last 12 months
  • Long-term anticoagulation

Principal Findings:

The primary outcome, incidence of cardiovascular death, urgent revascularization, stroke, or bleeding (BARC ≥2), occurred in 13.4% of the switched DAPT group versus 26.3% of the unchanged DAPT group (p < 0.01).

Secondary outcomes:

  • Any ischemic event: 9.3% vs. 11.5% (p = 0.36), respectively for switched vs. unchanged DAPT
  • BARC bleeding ≥2: 4.0% vs. 14.9% (p < 0.01), respectively for switched vs. unchanged DAPT

Interpretation:

Among patients who were event free after treatment for an acute coronary syndrome and initially treated with 1 month of aspirin/newer ADP antagonist, de-escalation of long-term antiplatelet therapy to aspirin/clopidogrel was beneficial. This strategy was associated with a reduction in bleeding (BARC ≥2), which is defined as any overt hemorrhage that is actionable and requires diagnostic studies, hospitalization, or treatment by a healthcare professional. Ischemic events were similar between the treatment groups.

References:

Cuisset T, Deharo P, Quilici J, et al. Benefit of switching dual antiplatelet therapy after acute coronary syndrome: the TOPIC (timing of platelet inhibition after acute coronary syndrome) randomized study. Eur Heart J 2017;May 16:[Epub ahead of print].

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias, Interventions and ACS

Keywords: Acute Coronary Syndrome, Adenosine Diphosphate, Aspirin, Blood Platelets, Hemorrhage, Incidence, Myocardial Ischemia, Myocardial Revascularization, Platelet Aggregation Inhibitors, Primary Prevention, Stroke, Ticlopidine


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