745 Meta-analysis comparing the safety and efficacy of ticagrelor monotherapy after a short course of ticagrelor-based dual antiplatelet therapy versus standard therapy in complex percutaneous coronary interventions

Abstract

Abstract Aims Current guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor for 6–12 months after percutaneous coronary intervention (PCI). A shorter duration ticagrelor-based DAPT followed by ticagrelor monotherapy can significantly reduce bleeding events while preserving anti-ischaemic effects in patients undergoing conventional PCI. Whether this strategy can be safely and effectively applied to those patient that undergo ‘complex’ PCI is uncertain. Methods We performed a systematic search of randomized controlled trials comparing a short course of ticagrelor-based DAPT vs. standard DAPT in patients undergoing complex PCI. A mixed-effects Poisson regression model with random intervention effects was used to estimate the pooled incidence rate ratios (IRR) with 95% confidence intervals (CI). Results Out of 10 689 studies screened, three were identified for a total of 4176 participants on ticagrelor monotherapy after a short course of ticagrelor based DAPT, and 4209 on standard DAPT. Overall, the pooled analysis showed a strong evidence that compared to standard treatment, ticagrelor monotherapy after a short course of ticagrelor-based DAPT (1–3 months) reduced the risk of cardiovascular death [IRR 0.52; CI (0.28–0.96); P = 0.04; I2 = 0%], all-cause death [IRR 0.65; CI (0.49–0.86); P = 0.003; I2 = 0%], and any bleeding events [IRR 0.62; CI (0.47–0.81); P < 0.001; I2 = 44%]. Weak evidence was found of an association between the experimental strategy and a lower risk of myocardial infarction [IRR 0.79; CI (0.61–1.01); P = 0.06; I2 = 0%]. Instead, no significant difference in the risk of major bleeding [IRR 0.72; CI (0.48–1.08); P = 0.11; I2 = 61%], definite or probable stent thrombosis [IRR 0.77; CI (0.34–1.75); P = 0.53; I2 = 0%] and ischaemic stroke [IRR 0.83; CI (0.25–2.73); P = 0.76; I2 = 0%] was observed. We speculate that the observed mortality benefits might be related to the reduction of any bleeding events, mainly dictated by minor bleeding reduction, since major bleeding did not seem to be decreased in the shorter regimen group. Conclusion Among patients undergoing complex PCI, ticagrelor monotherapy after a short course of ticagrelor-based DAPT significantly reduced bleeding risk without increasing ischaemic risk. As complex PCI procedures are being increasingly performed nowadays, and more comorbid patients are being treated, more studies are required to confirm and explain these findings. This could lead to optimization of antiplatelet therapy across a broad spectrum of patients.