De-escalating Dual Antiplatelet Therapy to Ticagrelor Monotherapy in Acute Coronary Syndrome : A Systemic Review and Individual Patient Data Meta-Analysis of Randomized Clinical Trials

De-escalating Dual Antiplatelet Therapy to Ticagrelor Monotherapy in Acute Coronary Syndrome : A Systemic Review and Individual Patient Data Meta-Analysis of Randomized Clinical TrialsAnn Intern Med . 2025 Feb 18. doi: 10.7326/ANNALS-24-03102.AbstractBackground: The role of transitioning from shortdual antiplatelet therapy (DAPT) to potent P2Y12 inhibitor monotherapy in patients with acute coronary syndrome (ACS) undergoing drug-eluting stent (DES)implantation remains inconclusive.Purpose: To compare the effects of de-escalatingdual antiplatelet therapy to ticagrelor monotherapy versus standard dual antiplatelet therapy from randomized clinical trials in patients with acute coronary syndrome.Data sources: PubMed, EMBASE, Scopus, andClinicalTrials.gov from inception to 12 December 2024.Study selection: Randomized clinical trialscomparing de-escalating dual antiplatelet therapy to ticagrelor monotherapy versus ticagrelor-based standard dual antiplatelet therapy for 12 months, specifically in patients with acute coronary syndrome undergoing drug-eluting stent implantation.Data extraction: The coprimary end points werean ischemic end point (composite of death, nonprocedural [spontaneous] myocardial infarction, or stroke) and a bleeding end point (Bleeding Academic Research Consortium types 3 or 5 bleeding).Data synthesis: Individual patient data wereobtained from 3 trials (TICO [Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome], T-PASS [Ticagrelor Monotherapy in Patients Treated With New-Generation Drug-Eluting Stents for Acute Coronary Syndrome], and ULTIMATE-DAPT [Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 afterpercutaneous coronary intervention in patients with acute coronary syndromes]), including 9130 randomized patients with acute coronary syndrome; 3132 had ST-segment elevation myocardial infarction (STEMI), 3023 had non-STEMI (NSTEMI), and 2975 had unstable angina. The rate of the primary ischemic end point was not different between the ticagrelor monotherapy and standard dualantiplatelet therapy groups (1.7% vs. 2.1%; hazard ratio [HR], 0.85 [95% CI, 0.63 to 1.16]). The rate of the primary bleeding end point was lower in the ticagrelor monotherapy group (0.8% vs. 2.5%; HR, 0.30 [CI, 0.21 to 0.45]). These findings were consistent in patients with ST-segment elevation myocardial infarction, Non ST-segment elevation myocardial infarction, and unstable angina.Limitation: Other de-escalation strategies for modulating antiplatelet therapy were not included.Conclusion: In patients with acute coronarysyndrome undergoing drug-eluting stent implantation, de-escalating dual antiplatelet therapy to ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard dual antiplatelet therapy, without an increase in ischemic events, regardless of the type of acute coronary syndrome.Disclaimer:Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the ­­­STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.