Although dual antiplatelet therapy (DAPT) remains the standard treatment to prevent stent thrombosis after percutaneous coronary intervention (PCI), ongoing trials are investigating alternative strategies such as a shorter duration of DAPT followed by monotherapy to reduce the risk of bleeding. According to data from the randomized GLOBAL LEADERS trial presented at the 2018 ESC Congress, treatment with ticagrelor for 2 years after PCI (with aspirin during the first month) shows no benefit compared with standard DAPT.
The initial hypothesis was that ticagrelor, a potent P2Y12-receptor antagonist that reduces adverse cardiac outcomes in patients with acute coronary syndrome (ACS), could prevent ischaemic events while avoiding bleeding complications in patients after PCI.
A total of 15,968 patients with stable coronary artery disease (CAD) or ACS undergoing PCI with drug-eluting stent implantation were randomly assigned to receive aspirin and ticagrelor daily for 1 month, followed by 23 months of ticagrelor monotherapy, or standard DAPT with aspirin and another antiplatelet agent — either clopidogrel for stable CAD or ticagrelor for ACS — daily for 1 year, followed by aspirin monotherapy for 1 year.
At 2 years, the primary end point of all-cause mortality or nonfatal new Q-wave myocardial infarction occurred in 3.81% of participants in the experimental group and 4.37% of participants in the control group (rate ratio 0.87, 95% CI 0.75–1.01, P = 0.073), and the frequency of bleeding was similar between the groups. Subgroup analysis also revealed no significant difference in the effects of the treatments in patients with stable CAD versus those with ACS.
In conclusion, while other trials on antiplatelet strategies are underway, the results of this trial do not support a change in clinical practice at this time.
References
Original article
Vranckx, P. et al. Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: a multicentre, open-label, randomised superiority trial. Lancet 392, 940–949 (2018)
Further reading
Miyazaki, Y. et al. Single or dual antiplatelet therapy after PCI. Nat. Rev. Cardiol. 14, 294–303 (2017)
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Le Bras, A. Ticagrelor not superior to DAPT after PCI. Nat Rev Cardiol 15, 655 (2018). https://doi.org/10.1038/s41569-018-0099-4
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DOI: https://doi.org/10.1038/s41569-018-0099-4