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Age and Ticagrelor Monotherapy in Patients Undergoing PCI
Quick Takes
- Ticagrelor monotherapy, compared with ticagrelor plus aspirin, reduced the incidence of clinically relevant bleeding over 1 year by almost 50% in patients ≥65 years of age.
- Ticagrelor monotherapy was not associated with significant differences in the rate of all-cause death, MI, or stroke in patients ≥65 years of age.
- In high-risk patients undergoing PCI, after a short DAPT course, P2Y12 inhibitor monotherapy with ticagrelor appears to be a safe bleeding-avoidance strategy, irrespective of age.
Study Questions:
What is the impact of age on the safety and efficacy of ticagrelor monotherapy after percutaneous coronary intervention (PCI)?
Methods:
The investigators evaluated the primary bleeding and secondary ischemic endpoints in the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial according to patient age for the present analysis. In particular, patients ≥65 years of age, a key clinical entry criterion, were compared with those <65 years of age. The TWILIGHT trial enrolled patients undergoing PCI with drug-eluting stents who fulfilled ≥1 clinical and 1 angiographic high-risk criterion. After 3 months of dual antiplatelet therapy (DAPT) with ticagrelor, event-free patients were randomized to ticagrelor plus placebo or ticagrelor plus aspirin for an additional 12 months. The primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding. The key secondary endpoint was the composite of all-cause death, myocardial infarction (MI), or stroke. Hazard ratios (HRs) and 95% confidence intervals (CIs) were generated using unadjusted Cox proportional hazards models.
Results:
A total of 3,113 patients (47.7%) were ≥65 years of age. At 1 year after randomization, ticagrelor monotherapy significantly reduced BARC type 2, 3, or 5 bleeding (4.5% vs. 8.2%; HR, 0.53; 95% CI, 0.40-0.71) without increasing ischemic events (4.2% vs. 4.4%; HR, 0.96; 95% CI, 0.68-1.35) compared with ticagrelor plus aspirin among patients ≥65 years of age. These findings were consistent in patients <65 years of age with respect to the primary (p for interaction = 0.62) and key secondary (p for interaction = 0.77) endpoints and across different age categories.
Conclusions:
The authors concluded that a strategy of ticagrelor monotherapy following 3 months of DAPT significantly reduced clinically relevant bleeding compared with ticagrelor plus aspirin without an increase in ischemic events, irrespective of age.
Perspective:
This subgroup analysis reports that ticagrelor monotherapy, compared with ticagrelor plus aspirin, reduced the incidence of clinically relevant bleeding over 1 year by almost 50% in patients ≥65 years of age. Furthermore, ticagrelor monotherapy was not associated with significant differences in the rate of all-cause death, MI, or stroke in patients ≥65 years of age and the treatment effect of ticagrelor monotherapy on ischemic and bleeding outcomes was preserved irrespective of age. These data suggest that in high-risk patients undergoing PCI, after a short DAPT course, P2Y12 inhibitor monotherapy with ticagrelor is a safe bleeding-avoidance strategy, irrespective of age. Given the subgroup nature of the analysis, adequately powered prospective studies are indicated to confirm the study findings.
Clinical Topics: Acute Coronary Syndromes, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Interventions and ACS
Keywords: Acute Coronary Syndrome, Aspirin, Drug-Eluting Stents, Geriatrics, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Primary Prevention, Purinergic P2Y Receptor Antagonists, Stroke
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