Stopping aspirin 1 month after drug-eluting stent implantation feasible for patients with ACS
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Key takeaways:
- Ticagrelor monotherapy after less than 1 month of dual antiplatelet therapy was noninferior to 12-month DAPT for patients with ACS who received a drug-eluting stent.
- Aspirin was stopped after a median of 16 days.
SAN FRANCISCO — In patients with ACS, stopping aspirin for ticagrelor monotherapy within 1 month of receiving a drug-eluting stent did not increase adverse CV and bleeding events compared with 12 months of dual antiplatelet therapy.
Data from the T-PASS study, presented at TCT 2023, demonstrated that less than 1 month of DAPT followed by ticagrelor monotherapy met a noninferiority threshold and provided evidence of superiority to 12 months of ticagrelor-based DAPT for a 1-year composite of adverse events, primarily due to a significant reduction in bleeding, Myeong-Ki Hong, MD, PhD, professor of medicine at Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea, said during a press conference. Researchers have not exclusively evaluated a switch to ticagrelor monotherapy within 1 month after DES for patients with ACS, Hong said.
“The shortest duration of DAPT — less than 1 month — is available [as a strategy] in patients with ACS when ticagrelor is used,” Hong told Healio. “Going forward, we will need to compare between ticargrelor and prasugrel monotherapy in ACS patients.”
For the open-label, noninferiority trial, Hong and colleagues analyzed data from 2,850 adults with ACS who underwent implantation of an ultrathin biodegradable polymer sirolimus-eluting stent (Orsiro, Biotronik) at 24 centers in South Korea. The mean age of patients was 61 years, 83% were men and 40% had STEMI. Researchers randomly assigned patients to receive ticagrelor monotherapy (90 mg twice daily) after less than 1 month of DAPT (n = 1,426) or 12 months of ticagrelor-based DAPT (n = 1,424). The primary endpoint was 1-year net clinical benefit, defined as a composite of all-cause death, MI, stent thrombosis, stroke and major bleeding.
The findings were simultaneously published in Circulation.
Among patients who received ticagrelor monotherapy after DAPT, aspirin was discontinued after a median of 16 days.
The primary endpoint occurred in 2.8% of patients who received ticagrelor monotherapy and 5.2% of patients who received continued DAPT (HR = 0.54; 95% CI, 0.37-0.8; P < .001 for noninferiority; P = .002 for superiority).
Patients in the ticagrelor monotherapy group had significantly less major bleeding compared with the extended DAPT group, with rates of 1.2% vs. 3.4% (HR = 0.35; 95% CI, 0.2-0.61; P < .001). There was no between-group difference in MACE at 1 year.
“In the present trial, the aspirin was discontinued at a median of 16 days, and this suggests that less than 1 month of DAPT is feasible if ticagrelor monotherapy is maintained, even in patients with ACS,” the researchers wrote in Circulation. “However, of note, the survival curves of the primary endpoint did not diverge much until 150 days, indicating the trade-off between major bleeding and ischemic [risk] in this period, even though the curves of the major bleeding separated at 30 days much earlier than those of the primary endpoint.”
The researchers noted that the low event rates in T-PASS may suggest enrollment of relatively non-high-risk patients, which should be considered when interpreting the results.
Reference:
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We have had several studies — TWILIGHT and others — demonstrating that 3 months of DAPT before a switch to ticagrelor monotherapy is effective. In T-PASS, the researchers are peeling back the envelope more, showing that even 1 month of DAPT or less is sufficient after following these patients for 1 year with this short aspirin protocol — the average was 16 days — and continuing ticagrelor for 1 year. The net adverse events were significantly less in the group that received short use of aspirin with long-term ticagrelor. The results were noninferior and showed evidence of superiority, primarily because with less antiplatelet agents they saw less bleeding. These results are promising.
Perhaps we have been thinking about this the wrong way. We always assumed aspirin first then a P2Y12 inhibitor for adequate DAPT. Really, we probably had it backward; we should have started with the P2Y12 inhibitor, particularly an effective one like ticagrelor first, and then add aspirin and have aspirin discontinued first. Studies like T-PASS are showing that a good, effective agent like ticagrelor and short-duration aspirin is the best strategy.
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Hong MK, et al. Late-breaking clinical trials: Session II, in collaboration with The Lancet. Presented at: TCT Scientific Symposium; Oct. 23-26, 2023; San Francisco (hybrid meeting).
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