Coronary disease & ACSMeta-analysis
De-escalation to ticagrelor monotherapy versus 12 months of dual antiplatelet therapy in patients with and without acute coronary syndromes: a systematic review and individual patient-level meta-analysis of randomised trials
- Systematic review and individual patient-level meta-analysis of randomised trials
- centrally adjudicated endpoints
- non-inferiority
De-escalation a median of 78 days (IQR 31-92) after intervention
Authors' conclusion
Our study found robust evidence that, compared with 12 months of DAPT, de-escalation to ticagrelor monotherapy does not increase ischaemic risk and reduces the risk of major bleeding, especially in patients with ACS.
Study context
- Population
- Patients undergoing PCI with a coronary drug-eluting stent, with and without acute coronary syndrome (ACS); long-term OAC indication excluded
- Participants
- 24,407 patients · 6 trials
- Comparison
- De-escalation to ticagrelor monotherapy vs 12-month dual antiplatelet therapy (DAPT)
- Outcome
- Three ranked coprimary endpoints: MACCE (all-cause death, MI or stroke; non-inferiority, per-protocol); Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding and all-cause death (superiority, ITT)
Pooled result
MACCE:
Hazard ratio
0.91
95% CI 0.78–1.07
P = 0.0039 for non-inferiority
Events by group
Ticagrelor monotherapy vs DAPT
HR 0.91 (95% CI 0.78–1.07); P for non-inferiority = 0.0039
As reported in the abstract
Further pooled results
| Outcome | Ticagrelor monotherapy | DAPT | HR (95% CI) | P value | |
|---|---|---|---|---|---|
| All-cause death (coprimary, ITT) · τ2<0.0001 · intention-to-treat population · Kaplan-Meier estimates | 0.9% | 1.2% | 0.76 (0.59–0.98) | P for superiority = 0.034 | |
| 0.512Hazard ratio (log scale) |
Heterogeneity by subgroup
- MACCE by sex, possible benefit in women with ticagrelor monotherapy
- P for interaction = 0.041
- All-cause death by sex
- P for interaction = 0.050
- Bleeding by clinical presentation, benefit in ACS with ticagrelor monotherapy
- P for interaction = 0.022
Safety
| Outcome | Ticagrelor monotherapy | DAPT | HR (95% CI) | P value | |
|---|---|---|---|---|---|
| BARC 3 or 5 bleeding (coprimary, ITT) · τ2=0.079 · intention-to-treat population · Kaplan-Meier estimates | 0.9% | 2.1% | 0.43 (0.34–0.54) | P for superiority < 0.0001 | |
| 0.20.5125Hazard ratio (log scale) |
Original publication
De-escalation to ticagrelor monotherapy versus 12 months of dual antiplatelet therapy in patients with and without acute coronary syndromes: a systematic review and individual patient-level meta-analysis of randomised trials. Lancet. Published 31 August 2024. doi:10.1016/s0140-6736(24)01616-7
Summarised from the published abstract; every number is checked against it