Ticagrelor Monotherapy After PCI Shows Promise: Lower Bleeding Risk, No Increased Revascularization

The Promise of Ticagrelor Monotherapy After PCI

New evidence from the TWILIGHT trial suggests that ticagrelor monotherapy after three months of dual antiplatelet therapy (DAPT) does not increase the risk of repeat revascularization or major adverse cardiovascular and cerebrovascular events (MACCE) after percutaneous coronary intervention (PCI). Additionally, ticagrelor monotherapy demonstrates a lower risk of bleeding. These findings shed light on the potential benefits of ticagrelor monotherapy as an alternative treatment strategy for patients undergoing PCI.

Background and Study Design

The TWILIGHT trial evaluated the efficacy and safety of ticagrelor plus aspirin versus ticagrelor alone for bleeding and ischemic adverse events in patients three months after PCI. The trial included 7,119 patients who were randomized to receive either ticagrelor plus aspirin or ticagrelor monotherapy. The primary outcome assessed was clinically driven revascularization, defined as repeat PCI or coronary artery bypass grafting (CABG) for recurrent or persistent symptomatic ischemia.

Revascularization Risk in Ticagrelor Monotherapy

The recent analysis of the TWILIGHT trial focused on comparing the rate of repeat revascularization between patients who switched to ticagrelor monotherapy after three months of DAPT and those who continued DAPT. The findings revealed no significant difference in clinically driven revascularization at one year between the two groups. This indicates that ticagrelor monotherapy does not increase the risk of revascularization compared to continued DAP.

Bleeding Risk and Net Adverse Cardiac Events

One of the notable benefits observed in the analysis was the lower risk of bleeding associated with ticagrelor monotherapy. The study showed that ticagrelor monotherapy was associated with a lower risk of net adverse cardiac events compared to DAPT. This reduction in adverse events was primarily driven by a lower incidence of bleeding. These findings suggest that ticagrelor monotherapy may offer a favorable balance between efficacy and safety after PCI.

Subgroup Analysis and Further Considerations

The analysis also explored the impact of ticagrelor monotherapy in specific patient subgroups[^1^]. Subgroup analyses stratified by PCI complexity, acute coronary syndrome (ACS) status, and diabetes status revealed no significant differences in clinically driven revascularization between ticagrelor monotherapy and DAPT[^1^]. These results indicate that ticagrelor monotherapy is equally effective in preventing repeat revascularization across various patient populations.

Expert Perspectives and Future Directions

Cardiologists specializing in interventional procedures have welcomed the findings of the TWILIGHT trial and the potential implications of ticagrelor monotherapy after PCI. Dr. Karim M. Al-Azizi highlights the reduction in net adverse clinical events with ticagrelor monotherapy and its potential to replace traditional DAPT in high-risk PCI patients. Dr. Jay Widmer emphasizes the importance of shorter DAPT regimens to reduce bleeding risk without compromising ischemic outcomes. However, several unanswered questions remain, such as the long-term use and dosing of ticagrelor monotherapy. Further research and data are needed to guide clinical practice in the future.

Conclusion

The analysis of the TWILIGHT trial provides valuable insights into the use of ticagrelor monotherapy after PCI. The study demonstrates that ticagrelor monotherapy does not increase the risk of revascularization and offers a lower bleeding risk compared to continued DAPT. These findings support the potential adoption of ticagrelor monotherapy as an effective and safe treatment strategy for patients undergoing PCI. Further research and longer-term studies are necessary to establish optimal dosing and long-term outcomes for this approach in clinical practice.