Abstract
Background: P2Y12 inhibitor monotherapy is an alternative antiplatelet strategy in patients undergoing percutaneous coronary intervention (PCI). However, the ideal P2Y12 inhibitor for monotherapy is unclear. Methods and Results: We performed a multicenter, retrospective, observational study to compare the efficacy and safety of monotherapy with clopidogrel versus ticagrelor in patients with acute coronary syndrome (ACS) undergoing PCI. From 1 January 2014 to 31 December 2018, 610 patients with ACS who received P2Y12 monotherapy with either clopidogrel (n = 369) or ticagrelor (n = 241) after aspirin was discontinued prematurely were included. Inverse probability of treatment weighting was used to balance covariates between the groups. The primary endpoint was the composite of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months after discharge. Overall, 84 patients reached the primary endpoint, with 57 (15.5%) in the clopidogrel group and 27 (11.2%) in the ticagrelor group. Multivariate adjustment in Cox proportional-hazards models revealed a lower risk of the primary endpoint with ticagrelor than with clopidogrel (adjusted hazard ratio (aHR): 0.67, 95% confidence interval (CI): 0.49–0.93). Ticagrelor significantly reduced the risk of recurrent ACS or unplanned revascularization (aHR: 0.46, 95% CI: 0.28–0.75). No significant difference in all-cause mortality and major bleeding events was observed between the 2 groups. Conclusions: Among patients with ACS undergoing PCI who cannot complete course of dual antiplatelet therapy, a significantly lower risk of cardiovascular events was associated with ticagrelor monotherapy than with clopidogrel monotherapy. The major bleeding risk was similar in both the groups.
Highlights
P2Y12 inhibitor monotherapy is an alternative antiplatelet strategy in patients undergoing percutaneous coronary intervention (PCI)
The inclusion criteria were as follows: men or women (1) aged ≥ 18 years, (2) who were hospitalized and survived to be discharged with acute coronary syndrome (ACS) as a major diagnosis, (3) who were treated with PCI during admission, (4) who regularly followed up in an outpatient clinic for at least 1 year after discharge, and (5) for whom aspirin was stopped within 6 months after PCI and monotherapy was used with clopidogrel 75 mg daily or ticagrelor 90 mg twice daily
The proportion of patients with aspirin discontinuation because of bleedings was similar between the groups but that because of the requirement of oral anticoagulation treatment was higher in the clopidogrel group than in the ticagrelor group (28.5% vs. 7.1%, p < 0.001; Table 1)
Summary
P2Y12 inhibitor monotherapy is an alternative antiplatelet strategy in patients undergoing percutaneous coronary intervention (PCI). STOPDAPT-2 and SMART-CHOICE trials were performed in Japan and Korea, the majority of which used clopidogrel monotherapy (60% in STOPDAPT-2 and 77% in SMART-CHOICE) [8,9] These trials concluded that P2Y12 inhibitor monotherapy is noninferior or superior to conventional DAPT for ischemic events at 1-year follow-up after PCI, and the risk of major bleeding was similar or lower in the P2Y12 inhibitor monotherapy group. These clinical trials showed that early aspirin-free strategy with P2Y12 inhibitor monotherapy might be an alternative after PCI. The efficacy and safety of clopidogrel versus ticagrelor were compared in these patients
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