Highlights from

AHA 2019

American Heart Association’s Scientific Sessions

Philadelphia, USA 16 - 18 November 2019

Drop Aspirin after 3 Months in Non-STEMI ACS Patients on Dual Antiplatelet Therapy

In a sub-analysis of the TWILIGHT trial, looking only at patients with acute coronary syndrome (ACS), researchers confirmed that dropping aspirin after 3 months of dual antiplatelet therapy (DAPT) with ticagrelor following percutaneous coronary intervention (PCI) lowers bleeding risk without increasing the rate of ischaemic events. The benefit observed with ticagrelor monotherapy is the same across different levels of risk and regardless of NSTEMI or unstable angina presentation.

Prof. Usman Baber (Icahn School of Medicine at Mount Sinai, New York, USA) provided the rationale for the study: “The basis for dual antiplatelet therapy in ACS really comes from trials conducted almost 20 years ago showing that DAPT is superior to aspirin,” but he noted that “one of the challenges we have with provision of antiplatelet therapy right now is a lot of patients who should be getting probably potent agents are not getting them due to concerns of bleeding” [1].

In TWILIGHT, 4,614 patients presented with ACS, including 2,494 with unstable angina and 2,120 with NSTEMI. Mean patient age was 64.2 years, more than one-third had diabetes, and about one-quarter each were current smokers or had a previous myocardial infarction (MI). Total stent length was about 40 mm in both study groups.

The primary endpoint of BARC 2, 3, or 5 bleeding was significantly lower at 1 year in the ticagrelor monotherapy group compared with continued aspirin (3.6% vs 7.6%; HR 0.47; 95% CI 0.36-0.61). Additionally, there was no difference between the study groups in the secondary outcome of death, MI, and stroke at 1 year (4.3% vs 4.4%; HR 0.97; 95% CI 0.74-1.28). Both findings remained consistent regardless of risk factor burden and presentation with unstable angina or NSTEMI.

Ticagrelor monotherapy was also associated with less bleeding compared with continued DAPT with regard to all prespecified bleeding endpoints including BARC 3 or 5 (0.8% vs 2.1%; P<0.0001), thrombolysis in myocardial infarction major bleeding (0.5% vs 1.0%; P=0.08), GUSTO moderate or severe (0.6% vs 1.6%; P=0.002), and ISTH major (0.9% vs 2.2%; P=0.001). All individual prespecified ischaemic endpoints were similar between the study cohorts including cardiovascular death, MI, or stroke; all-cause death; any MI; ischaemic stroke, and definite/probable stent thrombosis.

Independent predictors of death, MI, or stroke were identified as positive troponins (HR 1.77), established vascular disease (HR 2.77), atherectomy use (HR 2.46), and BARC 3 or 5 bleeding (HR 6.7).

  1. Baber U, et al. Ticagrelor with aspirin or alone in high-risk patients after coronary intervention for acute coronary syndrome. Session LBS04. American Heart Association Annual Scientific Sessions (AHA 2019), 14-18 November, Philadelphia, PA, USA.

Top image: @ iStockPhoto: Noctiluxx

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