Ticagrelor With or Without Aspirin in High-Risk Patients With Diabetes Mellitus Undergoing Percutaneous Coronary Intervention

Antiplatelet Therapy and Anticoagulation before, during, and after Acute Coronary Syndrome

Acute coronary syndrome (ACS) remains a major challenge in clinical practice, requiring rapid and effective antithrombotic treatment to mitigate adverse ischemic events while minimizing the risk of bleeding. In recent years, results from several clinical trials addressing this issue through various approaches have substantially improved the treatment landscape for patients presenting with ACS. The emergence of new, potent P2Y12 inhibitors has significantly enhanced thrombotic risk reduction and different strategies for de-escalating and shortening dual antiplatelet therapy (DAPT) have demonstrated promising outcomes in reducing bleeding rates. Furthermore, data from ongoing trials focusing on novel therapeutic agents and investigating alternative treatment strategies to optimize outcomes for ACS patients are expected in the next few years. In this review, we summarize the current knowledge and emphasize the critical role of individualized treatment approaches tailored to patient-specific risk factors and individual clinical scenarios.

Ticagrelor monotherapy after a short course of dual antiplatelet therapy with ticagrelor plus aspirin following percutaneous coronary intervention in patients with versus without diabetes mellitus: a meta-analysis of randomized trials

BACKGROUND

Cardiovascular disease (CVD) is one among the major causes of mortality all round the globe. Several anti-platelet regimens have been proposed following percutaneous coronary intervention (PCI). In this analysis, we aimed to show the adverse clinical outcomes associated with ticagrelor monotherapy after a short course of dual antiplatelet therapy (DAPT) with ticagrelor and aspirin following PCI in patients with versus without diabetes mellitus (DM).

METHODS

Electronic databases were searched by four authors from September to November 2023. Cardiovascular outcomes and bleeding events were the endpoints of this analysis. Revman 5.4 software was used to conduct this meta-analysis. Risk ratio (RR) and 95% confidence intervals (CI) were used to represent the results which were generated.

RESULTS

Three studies with a total number of 22,574 participants enrolled from years 2013 to 2019 were included in this analysis. Results of this analysis showed that DM was associated with significantly higher risks of major adverse cardiovascular events (RR: 1.73, 95% CI: 1.49 - 2.00; P = 0.00001), all-cause mortality (RR: 2.15, 95% CI: 1.73 - 2.66; P = 0.00001), cardiac death (RR: 2.82, 95% CI: 1.42 - 5.60; P = 0.003), stroke (RR: 1.78, 95% CI: 1.16 - 2.74; P = 0.009), myocardial infarction (RR: 1.63, 95% CI: 1.17 - 2.26; P = 0.004) and stent thrombosis (RR: 1.74, 95% CI: 1.03 - 2.94; P = 0.04) when compared to patients without DM. However, thrombolysis in myocardial infarction (TIMI) defined minor and major bleedings, bleeding defined according to the academic research consortium (BARC) type 3c (RR: 1.31, 95% CI: 0.14 - 11.90; P = 0.81) and BARC type 2, 3 or 5 (RR: 1.17, 95% CI: 0.85 - 1.62; P = 0.34) were not significantly different.

CONCLUSION

In patients who were treated with ticagrelor monotherapy after a short course of DAPT with ticagrelor and aspirin, DM was an independent risk factor for the significantly increased adverse cardiovascular outcomes. However, TIMI and BARC defined bleeding events were not significantly different in patients with versus without DM.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Duration of Dual Antiplatelet Treatment After Percutaneous Coronary Intervention in Patients With Diabetes: A Systematic Review and Meta-analysis

ABSTRACT

Aim of our systematic review and meta-analysis is to compare shortened (≤3 months) dual antiplatelet therapy (DAPT) with longer DAPT in diabetic patients undergoing percutaneous coronary interventions.We systematically screened 3 major databases (MEDLINE, Cochrane Central Register of Controlled Trials, and Scopus) searching for randomized-controlled trials or subanalyses of them, which compared shortened DAPT (S-DAPT) with longer DAPT regimens of DAPT. Primary end point of systematic review and meta-analysis is the net adverse clinical events (NACE), and secondary are major adverse cardiac events (MACE), mortality, bleedings, myocardial infarction, and stent thrombosis. Subgroup analyses included studies using only ticagrelor-based regimens and 3-month duration of DAPT.A total of 8 studies and 12,665 patients were included in our analysis. Our meta-analysis met its primary end point because S-DAPT was associated significantly with a reduced risk ratio (RR) by 17% [RR: 0.83, 95% confidence intervals (CI), 0.72-0.96]. Nonsignificant difference among the rest end points was detected between the 2 groups. Subgroup analyses showed that ticagrelor-based regimens were associated with a significant reduction of mortality (RR: 0.67, 95% CI, 0.48-0.93) and 3-month DAPT reduced furtherly NACE by 27% (RR: 0.73, 95% CI, 0.60-0.89).In conclusion, our systematic review and meta-analysis showed that (i) S-DAPT was significantly associated with a lower incidence of NACE, (ii) ticagrelor-based S-DAPT was associated with decreased mortality rates, and (iii) the benefit of 3-month duration of DAPT achieved an even greater NACE reduction. Thus, S-DAPT could be considered as a safe and feasible option in diabetic patients.

Optimal medical therapy improves outcomes in patients with diabetes mellitus and acute myocardial infarction

AIMS

We aimed to explored the association between the use of optimal medical therapy (OMT) in patients with myocardial infarction (AMI) and diabetes mellitus (DM) and clinical outcomes.

METHODS

Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome (BleeMACS) is an international registry that enrolled participants with acute coronary syndrome followed up for at least 1 year across 15 centers from 2003 to 2014. Baseline characteristics and endpoints were analyzed.

RESULTS

Among 3095 (23.2%) patients with AMI and DM, 1898 (61.3%) received OMT at hospital discharge. OMT was associated with significantly reduced mortality (4.3% vs. 10.8%, p < 0.001), re-AMI (4.4% vs. 8.1%, p < 0.001), and composite endpoint of death/re-AMI (8.0% vs. 17.6%, p < 0.001). No difference was observed among regions. Propensity score matching confirmed that OMT significantly associated with lower mortality. After adjusting for confounding variables, OMT, drug-eluting stents, and complete revascularization were independent protective factors of 1-year mortality, whereas left ventricular ejection fraction and age were risk factors.

CONCLUSIONS

Guideline-recommended OMT was prescribed at suboptimal frequencies with geographic variations in this worldwide cohort. OMT can improve long-term clinical outcomes in patients with DM and AMI.

CLINICAL TRIAL REGISTRATION

NCT02466854 June 9, 2015.

Bleeding and Ischemic Risks of Ticagrelor Monotherapy After Coronary Interventions

BACKGROUND

In TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention), among high-risk patients undergoing percutaneous coronary intervention (PCI), ticagrelor monotherapy vs continuation of dual antiplatelet therapy (DAPT) with aspirin and ticagrelor after completing a 3-month course of DAPT was associated with reduced bleeding, without an increase in ischemic events.

OBJECTIVES

This investigation sought to study the clinical benefit of ticagrelor monotherapy vs DAPT by simultaneously modeling its associated potential bleeding benefits and ischemic harms on an individual patient basis.

METHODS

Multivariable Cox regression models for: 1) Bleeding Academic Research Consortium type 2, 3, or 5 (BARC-2/3/5); and 2) cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke (major adverse cardiac and cerebrovascular event [MACCE]) were developed using stepwise forward variable selection. The coefficients in the BARC-2/3/5 and MACCE models were used to calculate bleeding and ischemic risk scores, respectively, for each patient (excluding the coefficient for randomized treatment).

RESULTS

In the total study group (N = 7,119), BARC-2/3/5 occurred in 391 (5.5%) patients, and MACCE occurred in 258 (3.6%). There was a consistent reduction in bleeding events associated with ticagrelor monotherapy compared with DAPT across both bleeding and ischemic risk strata (P interaction = 0.54 and 0.11, respectively). Importantly, this benefit associated with ticagrelor monotherapy was not offset by an increase in MACCE at any level of bleeding or ischemic risk.

CONCLUSIONS

Three months after PCI, discontinuing aspirin and maintaining ticagrelor monotherapy reduces bleeding in both higher-bleeding risk and lower-bleeding risk patients compared with continued DAPT. This benefit does not appear to be offset by greater ischemic risk. (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention [TWILIGHT]; NCT02270242).

Tailoring oral antiplatelet therapy in acute coronary syndromes: from guidelines to clinical practice

The assessment of bleeding and ischemic risk is a crucial step in establishing appropriate composition and duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS) treated with percutaneous coronary angioplasty. Evidence from recent randomized clinical trials led to some paradigm shifts in current guidelines recommendations. Options alternative to the standard 12-month DAPT duration include shorter periods of DAPT followed by single antiplatelet treatment with either aspirin or P2Y12 monotherapy, guided or unguided de-escalation DAPT, prolonged DAPT beyond the 12-month treatment period. Although DAPT composition and duration should be selected for each ACS patient on an individual basis weighing clinical and procedural variables, data from latest trials and meta-analyses may permit suggesting the most appropriate DAPT strategy according to the ischemic and bleeding risk assessed using validated tools and scores.

Clopidogrel Monotherapy After 1-Month Dual Antiplatelet Therapy in Patients With Diabetes Undergoing Percutaneous Coronary Intervention

BACKGROUND

Diabetes was reported to be associated with an impaired response to clopidogrel.

OBJECTIVES

The aim of this study was to evaluate the safety and efficacy of clopidogrel monotherapy after very short dual antiplatelet therapy (DAPT) in patients with diabetes undergoing percutaneous coronary intervention (PCI).

METHODS

A subgroup analysis was conducted on the basis of diabetes in the STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2) Total Cohort (N = 5,997) (STOPDAPT-2, n = 3,009; STOPDAPT-2 ACS [Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS], n = 2,988), which randomly compared 1-month DAPT followed by clopidogrel monotherapy with 12-month DAPT with aspirin and clopidogrel after cobalt-chromium everolimus-eluting stent implantation. The primary endpoint was a composite of cardiovascular (cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) or bleeding (TIMI [Thrombolysis In Myocardial Infarction] major or minor) endpoints at 1 year.

RESULTS

There were 2,030 patients with diabetes (33.8%) and 3967 patients without diabetes (66.2%). Regardless of diabetes, the risk of 1-month DAPT relative to 12-month DAPT was not significant for the primary endpoint (diabetes, 3.58% vs 4.12% [HR: 0.87; 95% CI: 0.56-1.37; P = 0.55]; nondiabetes, 2.46% vs 2.49% [HR: 0.99; 95% CI: 0.67-1.48; P = 0.97]; P_interaction = 0.67) and for the cardiovascular endpoint (diabetes, 3.28% vs 3.05% [HR: 1.10; 95% CI: 0.67-1.81; P = 0.70]; nondiabetes, 1.95% vs 1.43% [HR: 1.38; 95% CI: 0.85-2.25; P = 0.20]; P_interaction = 0.52), while it was lower for the bleeding endpoint (diabetes, 0.30% vs 1.50% [HR: 0.20; 95% CI: 0.06-0.68; P = 0.01]; nondiabetes, 0.61% vs 1.21% [HR: 0.51; 95% CI: 0.25-1.01; P = 0.054]; P_interaction = 0.19).

CONCLUSIONS

Clopidogrel monotherapy after 1-month DAPT compared with 12-month DAPT reduced major bleeding events without an increase in cardiovascular events regardless of diabetes, although the findings should be considered as hypothesis generating, especially in patients with acute coronary syndrome, because of the inconclusive result in the STOPDAPT-2 ACS trial. (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 [STOPDAPT-2], NCT02619760; Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS [STOPDAPT-2 ACS], NCT03462498).

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Treatment of the New Era: Long-Term Ticagrelor Monotherapy for the Treatment of Patients with Type 2 Diabetes Mellitus following Percutaneous Coronary Intervention: A Meta-analysis

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a risk factor for the development of coronary artery disease (CAD). In patients with acute coronary syndrome (ACS), guidelines recommend a potent P2Y12 inhibitor in addition to aspirin. For those with complicated and advanced CAD requiring complex percutaneous coronary intervention (PCI), the risk for adverse ischemic events is even higher. Prolonged dual antiplatelet therapy (DAPT) use is controversial. A new antiplatelet regimen after PCI should be considered. In this analysis, we aimed to systematically show the impact of long-term ticagrelor monotherapy after a short course of DAPT use on the outcomes in patients with T2DM following PCI.

METHODS

Electronic databases were searched for relevant publications. Studies that were based on patients with T2DM and that included patients with T2DM were selected on the basis of the inclusion and exclusion criteria. Statistical analysis was carried out with RevMan software. The data are presented as risk ratios (RR) with 95% confidence intervals (CI).

RESULTS

A total of 8621 patients were included in this analysis, whereby 4357 participants with T2DM were assigned to ticagrelor monotherapy and 4264 were assigned to DAPT. Our results showed long-term ticagrelor monotherapy after a short course of DAPT use to be associated with a significantly lower risk of major adverse cardiac events (RR 0.86, 95% CI 0.77-0.98; P = 0.02) and all-cause mortality (RR 0.77, 95% CI 0.60-0.98; P = 0.03). However, no significant difference was observed in cardiac death, myocardial infarction, stroke, stent thrombosis, or repeated revascularization. Ticagrelor monotherapy was associated with significantly lower risk of thrombolysis in myocardial infarction (TIMI) defined minor or major bleeding (RR 0.71, 95% CI 0.54-0.93; P = 0.01) compared with the DAPT regimen.

CONCLUSION

Long-term ticagrelor monotherapy after a short course of DAPT use showed better results in patients with T2DM following PCI. Therefore, ticagrelor monotherapy after a short course of DAPT use could be considered an evolution in antiplatelet therapy of this decade for the treatment of patients with T2DM after PCI. However, newer studies with a larger population size and cost-effectiveness are factors that should further be considered.

Ticagrelor with and without aspirin in patients with a prior coronary artery bypass graft undergoing percutaneous coronary intervention: the TWILIGHT-CABG study

BACKGROUND

Prior coronary artery bypass graft surgery (CABG) patients undergoing percutaneous coronary intervention (PCI) are often older and present with multiple comorbidities. Ticagrelor monotherapy after a short course of dual antiplatelet therapy (DAPT) has emerged as an effective bleeding-avoidance strategy among high-risk patients.

AIMS

We aimed to examine the effects of ticagrelor with or without aspirin in prior CABG patients undergoing PCI within the TWILIGHT trial.

METHODS

After 3 months of ticagrelor plus aspirin, patients were randomised to either aspirin or placebo, in addition to ticagrelor, for 12 months and compared by prior CABG status. The primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding. The key secondary endpoint was all-cause death, myocardial infarction (MI), or stroke.

RESULTS

Out of 7,119 patients, a total of 703 (10.8%) patients had prior CABG within the randomised cohort. Prior CABG patients had more comorbidities and a higher incidence of BARC type 2, 3, or 5 bleeding and death, MI or stroke at 1 year after randomisation, compared with patients without prior CABG. Ticagrelor monotherapy was associated with significantly less BARC 2, 3, or 5 bleeding among prior CABG patients compared with DAPT (4.9% vs 9.6%, hazard ratio [HR] 0.50, 95% confidence interval [CI]: 0.28 to 0.90; pinteraction=0.676) and similar rates of death, MI or stroke (10.0% vs 8.7%, HR 1.14, 95% CI: 0.70 to 1.87; pinteraction=0.484). When comparing target vessel type, treatment effects were consistent among graft- and native-vessel interventions.

CONCLUSIONS

In high-risk patients with prior CABG, ticagrelor monotherapy reduced bleeding without compromising ischaemic outcomes compared with ticagrelor plus aspirin.

P2Y12 inhibitor monotherapy in patients undergoing percutaneous coronary intervention

For 20 years, dual antiplatelet therapy (DAPT), consisting of the combination of aspirin and a platelet P2Y₁₂ receptor inhibitor, has been the gold standard of antithrombotic pharmacology after percutaneous coronary intervention (PCI). In the past 5 years, several investigations have challenged this paradigm by testing the efficacy and safety of P2Y₁₂ inhibitor monotherapy (that is, without aspirin) following a short course of DAPT. Collectively, these studies suggested a reduction in the risk of major bleeding and no significant increase in thrombotic or ischaemic events compared with guideline-recommended DAPT. Current recommendations are evolving to inform clinical practice on the ideal candidates for P2Y₁₂ inhibitor monotherapy after PCI. Generalizing the results of studies of P2Y₁₂ inhibitor monotherapy requires a thorough understanding of their design, populations, interventions, comparators and results. In this Review, we provide an up-to-date overview on the use of P2Y₁₂ inhibitor monotherapy after PCI, including supporting pharmacodynamic and clinical evidence, practical recommendations and future directions.

Endothelial biomarkers and platelet reactivity on ticagrelor versus clopidogrel in patients after acute coronary syndrome with and without concomitant type 2 diabetes: a preliminary observational study

BACKGROUND

Pleiotropic effects have been implicated in clinical benefits of ticagrelor compared to thienopyridine P2Y₁₂ antagonists. There are conflicting data regarding effects of ticagrelor vs. thienopyridine P2Y₁₂ blockers on endothelial function. Our aim was to compare endothelial biomarkers and their relations with platelet reactivity in real-world patients after acute coronary syndrome (ACS) on maintenance dual antiplatelet therapy (DAPT) with ticagrelor or clopidogrel stratified by diabetes status.

METHODS

Biochemical indices of endothelial dysfunction/activation and platelet reactivity by multiple electrode aggregometry were compared in 126 stable post-ACS subjects (mean age: 65 ± 10 years, 92 men and 34 women), including patients with (n = 61) or without (n = 65) coexistent type 2 diabetes (T2DM) on uneventful maintenance DAPT with either ticagrelor (90 mg b.d.) or clopidogrel (75 mg o.d.) in addition to low-dose aspirin. Exclusion criteria included a complicated in-hospital course, symptomatic heart failure, left ventricular ejection fraction < 40% and relevant coexistent diseases except for well-controlled diabetes, mild renal insufficiency or hypertension.

RESULTS

Clinical characteristics were similar in patients on ticagrelor (n = 62) and clopidogrel (n = 64). The adenosine diphosphate-induced platelet aggregation and circulating soluble P-selectin (sP-selectin) were decreased in ticagrelor users irrespective of T2DM status (p < 0.001 and p < 0.01 for platelet reactivity and sP-selectin, respectively). Plasma levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) were lower in T2DM subjects on ticagrelor vs. clopidogrel (758 ± 162 vs. 913 ± 217 µg/L, p < 0.01). In contrast, plasma sVCAM-1 was similar in non-diabetic patients on ticagrelor and clopidogrel (872 ± 203 vs. 821 ± 210 µg/L, p > 0.7). The concentrations of sE-selectin, monocyte chemoattractant protein-1 and asymmetric dimethylarginine did not differ according to the type of P2Y₁₂ antagonist regardless of T2DM status. Platelet reactivity was unrelated to any endothelial biomarker in subjects with or without T2DM.

CONCLUSIONS

Our preliminary findings may suggest an association of ticagrelor-based maintenance DAPT with favorable endothelial effects compared to clopidogrel users in stable post-ACS patients with T2DM. If proven, this could contribute to more pronounced clinical benefits of ticagrelor in diabetic subjects.

Short dual antiplatelet therapy and dual antiplatelet therapy de-escalation after primary percutaneous intervention: For whom and how

Dual antiplatelet therapy (DAPT) for 6-12 months, followed by lifelong aspirin monotherapy is considered an effective standard therapy for the prevention of thrombo-ischemic events in patients with acute and chronic coronary syndrome (ACS, CCS) undergoing percutaneous coronary intervention (PCI) or after a primarily conservative treatment decision. In ACS patients, the stronger P2Y12-inhibitors ticagrelor or prasugrel are recommended in combination with aspirin unless the individual bleeding risk is high and shortening of DAPT is warranted or clopidogrel is preferred. However, also in patients at low individual bleeding risk, DAPT is associated with a higher risk of bleeding. In recent years, new antithrombotic treatment strategies, such as shortening DAPT followed by early P2Y12-inhibitor monotherapy and de-escalating DAPT from potent P2Y12-inhibitors to clopidogrel by maintaining DAPT duration time, have been investigated in clinical trials and shown to reduce bleeding complications in cardiovascular high-risk patients without negative effects on ischemic events. In this review, we summarize the current knowledge and discuss its implication on future antithrombotic strategies in terms of a personalized medicine.

Impact of intravascular ultrasound in acute myocardial infarction patients at high ischemic risk

INTRODUCTION AND OBJECTIVES

Evidence for the role of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in patients at high ischemic risk of acute myocardial infarction (AMI) is lacking. This study aimed to investigate the long-term clinical impact of IVUS-guided PCI in patients at high ischemic risk of AMI.

METHODS

Among 13 104 patients with AMI enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health, we selected 8890 patients who underwent successful PCI with second-generation drug-eluting stent implantation and classified them into 2 groups based on whether or not they were at high ischemic risk or not, defined as any of the following: number of stents implanted ≥ 3, 3 vessels treated, ≥ 3 lesions treated, total stent length> 60mm, left main PCI, diabetes mellitus, and chronic kidney disease. The primary outcome was target lesion failure including cardiac death, target vessel myocardial infarction, and ischemia-driven target lesion revascularization at 3 years.

RESULTS

In 4070 AMI patients at high ischemic risk, IVUS-guided PCI (21.6%) was associated with a significantly lower risk of target lesion failure at 3 years (6.7% vs 12.0%; HR, 0.54; 95%CI, 0.41-0.72; P <.001) than angiography-guided PCI. The results were consistent after confounder adjustment, inversed probability weighting, and propensity score matching.

CONCLUSIONS

In patients at high ischemic risk of AMI who underwent PCI with second-generation drug-eluting stent implantation, use of IVUS guidance was associated with a significant reduction in 3-year target lesion failure. iCreaT study No. C110016.

P2Y12 Inhibitor Monotherapy after Percutaneous Coronary Intervention

In patients with acute and chronic coronary artery disease undergoing percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) has been the cornerstone of pharmacotherapy for the past two decades. Although its antithrombotic benefit is well established, DAPT is associated with an increased risk of bleeding, which is independently associated with poor prognosis. The improvement of the safety profiles of drug-eluting stents has been critical in investigating and implementing shorter DAPT regimens. The introduction into clinical practice of newer generation oral P2Y₁₂ inhibitors such as prasugrel and ticagrelor, which provide more potent and predictable platelet inhibition, has questioned the paradigm of standard DAPT durations after coronary stenting. Over the last five years, several trials have assessed the safety and efficacy of P2Y₁₂ inhibitor monotherapy after a short course of DAPT in patients treated with PCI. Moreover, ongoing studies are testing the role of P2Y₁₂ inhibitor monotherapy immediately after PCI in selected patients. In this review, we provide up-to-date evidence on the efficacy and safety of P2Y₁₂ inhibitor monotherapy after a short period of DAPT compared to DAPT in patients undergoing PCI as well as outcomes associated with P2Y₁₂ inhibitor monotherapy compared to aspirin for long-term prevention.

The Evolution of Antiplatelet Therapy After Percutaneous Coronary Interventions: A 40-Year Journey

Antiplatelet therapy has a critical role to play in the successful management of patients undergoing percutaneous coronary intervention (PCI). Over the past 40 years, a multitude of participants worldwide have been enrolled in trials evaluating the impact of antiplatelet agents on clinical outcomes. The use of aspirin in unstable angina in the Canadian Aspirin trial was key to establishing the benefit of aspirin in acute coronary syndrome. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial demonstrated that the P2Y12 inhibitor clopidogrel, when added to aspirin, reduced major cardiovascular events. While the use of antiplatelet agents in coronary artery disease antedates the introduction of PCI and remains the cornerstone of secondary prevention of atherosclerotic cardiovascular disease, strategies aiming to optimise their best use are still constantly evolving. In this review, the major randomised trials shaping current clinical practice for the use of aspirin and P2Y12 inhibitors in patients undergoing PCI are summarised, with a focus on aspirin-free strategies and on the role of P2Y12 inhibitor treatment before PCI, two major topics of ongoing investigation that are critical to patient care but that are not addressed in current practice guidelines. Multiple questions remain regarding the use of antiplatelet agents after PCI, including the personalisation of dosing, intensity, pharmacologic formulation, and duration of antiplatelet therapy based on individual patient characteristics and the optimal treatment of patients at high bleeding risk.

Impact of one-month DAPT followed by aspirin monotherapy in patients undergoing percutaneous coronary intervention according to clinical presentation: a post hoc analysis of the randomised One-Month DAPT trial

BACKGROUND

The impact of 1-month dual antiplatelet therapy (DAPT) followed by aspirin monotherapy according to clinical presentation has not been elucidated.

AIMS

This study aimed to compare the impact of 1-month DAPT followed by aspirin monotherapy after polymer-free drug-coated stent (PF-DCS) implantation (1-month DAPT after PF-DCS) vs 6-12-month DAPT followed by aspirin monotherapy after biodegradable polymer drug-eluting stent (BP-DES) implantation (6-12-month DAPT after BP-DES) according to clinical presentation.

METHODS

This is a post hoc analysis of the One-Month DAPT trial. The primary outcome was the composite of major adverse cardiac and cerebrovascular events (MACCE; a composite of cardiac death, non-fatal myocardial infarction, target vessel revascularisation, and stroke) and major bleeding.

RESULTS

Among 1,828 patients with stable coronary artery disease (CAD), 1-month DAPT after PF-DCS resulted in lower rates of the primary outcome than 6-12-month DAPT after BP-DES (3.9% vs 6.5%; hazard ratio [HR] 0.59, 95% confidence interval [CI]: 0.39-0.90; p=0.012). However, among 1,192 patients with acute coronary syndrome (ACS), the rates of the primary outcome were not significantly different between the two therapy groups (5.6% vs 3.6%; HR 1.57, 95% CI: 0.91-2.70; p=0.102) and a significant interaction was observed between therapy and clinical presentation regarding the primary outcome (Pint=0.005). A significant interaction was observed in MACCE (Pint=0.016), but not in major bleeding (Pint=0.276).

CONCLUSIONS

In patients undergoing drug-eluting stent implantation for non-complex lesions, the benefits of 1-month DAPT followed by aspirin monotherapy for a composite of ischaemic and bleeding outcomes were found in patients with stable CAD, but not in those with ACS.

CLINICALTRIALS

gov: NCT02513810.

Opportunità cliniche e impatto sul sistema sanitario di un trattamento ottimale del paziente post-sindrome coronarica acuta

Despite the improvement of revascularization procedures, patients with acute coronary syndrome often develop recurrent ischemic events, suggesting a high residual cardiovascular risk in these patients, which requires a strict clinical monitoring as well as an optimal control of modifiable risk factors.

To this aim, an optimal management of index event and appropriate preventive measures are equally important. Hospital care by cardiologists should be followed by outpatient management by general practitioners, as established by specific diagnostic and therapeutic pathways, which should warrant an optimal support to the patient. A strict collaboration between hospital and primary care is crucial to monitor and adapt drug therapy after the acute event and improve adherence of the patients to prescribed treatments and implementation of life-style modifications, with benefits also in term of cost-effectiveness. In this context, individualized rehabilitation programs should also be offered to patients with acute coronary syndromes, in order to improve survival and quality of life.

Comparative Efficacy and Safety of P2Y12 Inhibitor Monotherapy and Dual Antiplatelet Therapy in Patients with and without Diabetes Mellitus Undergoing Percutaneous Coronary Intervention

Increasing evidence has shown P2Y12 inhibitor monotherapy is a feasible alternative treatment for patients after percutaneous coronary intervention (PCI) with stent implantation in the modern era. However, patients with diabetes mellitus (DM) have a higher risk of ischemic events and more complex coronary artery disease. The purpose of this study is to evaluate the efficacy and safety of this novel approach among patients with DM and those without DM. We conducted a systematic review and meta-analysis of randomized controlled trials that compared P2Y12 inhibitor monotherapy with 12 months of dual antiplatelet therapy (DAPT) in patients who underwent PCI with stent implantation. PubMed, Embase, Cochrane library database, ClinicalTrials.gov, and three other websites were searched for our data from the earliest report to January 2022. The primary efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE): a composite of all-cause mortality, myocardial infarction, stent thrombosis, and stroke. The primary safety outcome was major or minor bleeding events. The secondary endpoint was net adverse clinical events (NACE) which are defined as a composite of major bleeding and adverse cardiac and cerebrovascular events. A total of four randomized controlled trials with 29,136 patients were included in our meta-analysis. The quantitative analysis showed a significant reduction in major or minor bleeding events in patients treated with P2Y12 inhibitor monotherapy compared to standard DAPT (OR: 0.68, 95% CI: 0.46-0.99, p = 0.04) without increasing the risk of MACCE (OR: 0.96, 95% CI: 0.85-1.09, p = 0.50). The number of NACE was significantly lower in the patients treated with P2Y12 inhibitor monotherapy (OR: 0.84, 95% CI: 0.72-0.97, p = 0.019). In DM patients, P2Y12 inhibitor monotherapy was associated with a lower risk of MACCE compared to standard DAPT (OR: 0.85, 95% CI: 0.74-0.98, p = 0.02). Furthermore, P2Y12 inhibitor monotherapy was accompanied by a favorable reduction in major or minor bleeding events (OR: 0.80, 95% CI: 0.64-1.05, p = 0.107). In non-DM patients, P2Y12 inhibitor monotherapy showed a significant reduction in major or minor bleeding events (OR: 0.58, 95% CI: 0.38-0.88, p = 0.01), but without increasing the risk of MACCE (OR: 0.99, 95% CI: 0.82-1.19, p = 0.89). Based on these findings, P2Y12 inhibitor monotherapy could significantly decrease bleeding events without increasing the risk of stent thrombosis or myocardial infarction in the general population. The benefit of reducing bleeding events was much more significant in non-DM patients than in DM patients. Surprisingly, P2Y12 inhibitor monotherapy could lower the risk of MACCE in DM patients. Our study supports that P2Y12 inhibitor monotherapy is a promising alternative choice of medical treatment for patients with DM undergoing PCI with stent implantation in the modern era.

Antiplatelet therapy after percutaneous coronary intervention

Antiplatelet therapy is key to reducing local thrombotic complications and systemic ischaemic events among patients undergoing percutaneous coronary interventions (PCI), but it is inevitably associated with increased bleeding. The continuous refinement in stent technologies, together with the high incidence of ischaemic recurrences after PCI and the understanding of prognostic implications associated with bleeding, have led to a substantial evolution in antiplatelet treatment regimens over the past decades. Numerous investigations have been conducted to better stratify patients undergoing PCI according to their ischaemic and bleeding risks and to implement antithrombotic regimens accordingly. Evidence from these investigations have resulted in a number of antithrombotic treatment options as recommended by recent guidelines. In this State-of-the-Art review we provide the rationale, summarise the evidence, and discuss current and future directions of antiplatelet treatment regimens after PCI.

Naoxintong capsule limits myocardial infarct expansion by inhibiting platelet activation through the ERK5 pathway

BACKGROUND

In the clinic, Naoxintong capsule (NXT) has been applied in two level prevention of ischemic disease. However, its mechanism of action requires further study.

PURPOSE

This study investigated whether NXT could affect platelet function and activation under ischemic pathological conditions.

MATERIALS AND METHODS

Wistar rats were divided into six groups, sham, saline, NXT (250, 500, 1000 mg/kg), and aspirin group (10 mg/kg). For the pre-treatment assays, MI model was established after pre-administration of saline, NXT-L, NXT-M, NXT-H, and aspirin respectively for 14 days, and after surgery, there were no continuous treatments. For the post-treatment assay, rats were orally administered for 3 days after MI. FeCl3-induced thrombosis model was applied to determine the thrombus wet weight. Bleeding time was used to assess the ability of the platelets to develop a hemostatic plug.

RESULTS

NXT decreased infarct size, decreased LDH, CK, and CK-MB values, and improved cardiac function. NXT inhibited platelets activation through reducing CD62P-positive platelets and inhibited infarct expansion by decreasing the number of CD45-positive cells and the amount of MMP9 secreted into the heart tissue. Mechanistically, NXT inhibited platelets activation through decreasing ROS levels, decreasing ERK5 phosphorylation, and increasing RAC1 phosphorylation in MI rats. Pre-treatment with NXT decreased thrombus formation and had normal bleeding times.

CONCLUSION

NXT showed obviously preventive effects, which was associated with negative control of platelet activation. The above results provide a basis for clinically expanding application of NXT.

10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Antiplatelet and Antithrombotic Therapy in Type I Diabetes Mellitus: Update on Current Data

Diabetes mellitus type 1 (T1DM) is an autoimmune disease characterized by a markedly elevated cardiovascular (CV) risk due to premature atherosclerosis. Previous studies have shown that intense glycemic control reduces the incidence of CV disease. Antiplatelet therapy is considered to be a very important therapy for secondary prevention of recurrent atherothrombotic events in patients with DM, while it may be considered for primary prevention in individuals with T1DM with additional CV risk factors. The aim of the present review is to summarize existing literature data regarding the thrombotic risk in T1DM patients and discuss current treatment strategies.

Ticagrelor monotherapy in patients at high bleeding risk undergoing percutaneous coronary intervention: TWILIGHT-HBR

AIMS

Patients at high bleeding risk (HBR) represent a prevalent subgroup among those undergoing percutaneous coronary intervention (PCI). Early aspirin discontinuation after a short course of dual antiplatelet therapy (DAPT) has emerged as a bleeding avoidance strategy. The aim of this study was to assess the effects of ticagrelor monotherapy after 3-month DAPT in a contemporary HBR population.

METHODS AND RESULTS

This prespecified analysis of the TWILIGHT trial evaluated the treatment effects of early aspirin withdrawal followed by ticagrelor monotherapy in HBR patients undergoing PCI with drug-eluting stents. After 3 months of ticagrelor plus aspirin, event-free patients were randomized to 12 months of aspirin or placebo in addition to ticagrelor. A total of 1064 (17.2%) met the Academic Research Consortium definition for HBR. Ticagrelor monotherapy reduced the incidence of the primary endpoint of Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding compared with ticagrelor plus aspirin in HBR (6.3% vs. 11.4%; hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.35-0.82) and non-HBR patients (3.5% vs. 5.9%; HR 0.59, 95% CI 0.46-0.77) with similar relative (Pinteraction = 0.67) but a trend towards greater absolute risk reduction in the former [-5.1% vs. -2.3%; difference in absolute risk differences (ARDs) -2.8%, 95% CI -6.4% to 0.8%, P = 0.130]. A similar pattern was observed for more severe BARC 3 or 5 bleeding with a larger absolute risk reduction in HBR patients (-3.5% vs. -0.5%; difference in ARDs -3.0%, 95% CI -5.2% to -0.8%, P = 0.008). There was no significant difference in the key secondary endpoint of death, myocardial infarction, or stroke between treatment arms, irrespective of HBR status.

CONCLUSIONS

Among HBR patients undergoing PCI who completed 3-month DAPT without experiencing major adverse events, aspirin discontinuation followed by ticagrelor monotherapy significantly reduced bleeding without increasing ischaemic events, compared with ticagrelor plus aspirin. The absolute risk reduction in major bleeding was larger in HBR than non-HBR patients.

Guided and unguided de-escalation from potent P2Y12 inhibitors among patients with ACS: a meta-analysis

AIM

Optimal dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) intends to balance ischemic and bleeding risks. Various DAPT de-escalation strategies, defined as switching from a full-dose potent to a reduced dose or less potent P2Y12 inhibitor, have been evaluated in several ACS-PCI trials. We aimed to compare DAPT de-escalation to standard DAPT with full dose potent P2Y12 inhibitors in ACS patients who underwent PCI.

METHODS & RESULTS

PubMed, Google Scholar and Cochrane Central Register of Controlled Trials were searched for eligible randomised controlled trials. Aspirin monotherapy trials were excluded. Five randomised trials (n = 10,779 patients) that assigned DAPT de-escalation (genetically guided to clopidogrel n = 1,242; platelet function guided to clopidogrel n = 1,304; unguided to clopidogrel n = 1,672; unguided to lower dose n = 1,170) versus standard DAPT (control group n = 5,391) were included in this analysis. DAPT de-escalation was associated with a significant reduction in Bleeding Academic Research Consortium ≥ 2 bleeding (HR 0.57, 95% CI 0.42-0.78; I2 = 77%) as well as major adverse cardiac events, represented in most trials by the composite of cardiovascular mortality, myocardial infarction, stent thrombosis and stroke (HR 0.77, 95% CI 0.62-0.96; I2 = 0%). Notwithstanding the limited power, consistency was noted across various de-escalation strategies.

CONCLUSION

De-escalation of DAPT after PCI for ACS, both unguided and guided by genetic or platelet function testing, was associated with lower rates of clinically relevant bleeding and ischemic events as compared to standard DAPT with potent P2Y12 inhibitors based on five open-label RCTs reviewed.

Single antiplatelet therapy with use of prasugrel in patients undergoing percutaneous coronary intervention

OBJECTIVES

We aimed to assess the ischemic and bleeding risks of single antiplatelet therapy (SAPT) with prasugrel compared with standard dual antiplatelet therapy (DAPT) (aspirin plus clopidogrel for 1 year) in patients with chronic coronary syndrome (CCS) treated with new generation drug-eluting stents (DES).

BACKGROUND

To date, data on SAPT with potent P2Y12 inhibitors in the absence of aspirin immediately after PCI are limited.

METHODS

Between January 2009 and November 2019, all CCS patients undergoing percutaneous coronary intervention (PCI) enrolled to the Bern PCI registry were considered for analysis. We performed propensity score matching in a 1:4 fashion to compare patients who received SAPT with prasugrel versus standard DAPT. The primary ischemic endpoint was a composite of cardiovascular death, myocardial infarction, and stroke and the primary bleeding endpoint was BARC 3 or 5 bleeding, both assessed at 1 year.

RESULTS

After propensity score matching, the final study population consisted of 225 patients with SAPT and 889 with DAPT. There was no significant difference in rates of the primary ischemic (5.2% vs. 4.2%, p = .50) or the primary bleeding (1.5% vs. 2.0%, p = .60) endpoints between groups. SAPT was not associated with an increased risk of definite stent thrombosis (0.9% vs. 0.8%, p = .83).

CONCLUSIONS

Among selected CCS patients undergoing PCI with DES, SAPT with prasugrel was not associated with an excess of ischemic events compared with standard DAPT. No difference in bleeding was observed either. The results may serve as the basis for larger trials assessing the potential benefits and risks of SAPT.

Ticagrelor Monotherapy Versus Ticagrelor With Aspirin in Acute Coronary Syndrome Patients With a High Risk of Ischemic Events

[Figure: see text].

Clinical Outcomes of Very Short Term Dual Antiplatelet Therapy in Patients With or Without Diabetes Undergoing Second-Generation Drug-Eluting Stents: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background: Patients with diabetes represent 20-30% of the population considered for percutaneous coronary intervention (PCI) and associate with more deleterious clinical outcome, which requires the optimal strategy of dual antiplatelet therapy (DAPT). The meta-analysis aims to compare clinical outcomes between very short (1-3 months) and standard (12 months) DAPT after implanting the second-generation drug-eluting stents in patients with or without diabetes following PCI. Methods and Analysis: PubMed, Embase, Web of Science, Ovid, Cochrane Library, and ClinicalTrials.gov were searched for studies comparing the very short term and standard DAPT in patients with or without diabetes following PCI. Risk ratio with 95% confidence intervals was used to evaluate the pooled effect of discontinuous variables, and the pooled analyses were performed with RevMan 5.3 and Stata SE 14.0 software. Results: A total of 38,864 patients were randomized to the very short term DAPT (N = 19,423) vs. standard DAPT (N = 19,441). Among them, 11,476 patients were diabetes and 27,388 patients were non-diabetes. The primary outcome of the net adverse clinical event (NACE) was significantly lower in diabetic patients with very short term DAPT (risk ratio 0.72, 95% CI 0.60-0.88, p = 0.0009). The same result was also found in the major cardiac or cerebrovascular events (MACCEs) (0.87, 0.78-0.98, p = 0.03). The risk of major or minor bleeding was significantly reduced in very short term DAPT regardless of the diabetes statue (0.69, 0.52-0.93, p = 0.01 in the diabetic group, and 0.50, 0.39-0.63, p <0.0001 in the non-diabetic group). There was no statistical difference in the incidence of major bleeding, all-cause death, cardiac death, myocardial infarction, definite or probable stent thrombosis, and stroke between the very short term DAPT (1-3 months) and standard DAPT (12 months) in patients with or without diabetes. Conclusion: The very short term DAPT can significantly reduce the risk of the NACE and MACCE in patients with diabetes compared to standard DAPT. Meanwhile, the very short term DAPT can also reduce the incidence of major and minor bleeding without increasing the risk of ischemia in patients with or without diabetes (Registered by PROSPERO, CRD42020192133). Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, Identifier: CRD42020192133.

Antithrombotic therapy in diabetes: which, when, and for how long?

Cardiovascular disease remains the main cause of mortality in individuals with diabetes mellitus (DM) and also results in significant morbidity. Premature and more aggressive atherosclerotic disease, coupled with an enhanced thrombotic environment, contributes to the high vascular risk in individuals with DM. This prothrombotic milieu is due to increased platelet activity together with impaired fibrinolysis secondary to quantitative and qualitative changes in coagulation factors. However, management strategies to reduce thrombosis risk remain largely similar in individuals with and without DM. The current review covers the latest in the field of antithrombotic management in DM. The role of primary vascular prevention is discussed together with options for secondary prevention following an ischaemic event in different clinical scenarios including coronary, cerebrovascular, and peripheral artery diseases. Antiplatelet therapy combinations as well as combination of antiplatelet and anticoagulant agents are examined in both the acute phase and long term, including management of individuals with sinus rhythm and those with atrial fibrillation. The difficulties in tailoring therapy according to the variable atherothrombotic risk in different individuals are emphasized, in addition to the varying risk within an individual secondary to DM duration, presence of complications and predisposition to bleeding events. This review provides the reader with an up-to-date guide for antithrombotic management of individuals with DM and highlights gaps in knowledge that represent areas for future research, aiming to improve clinical outcome in this high-risk population.

Advances in Clinical Cardiology 2020: A Summary of Key Clinical Trials

INTRODUCTION

Despite the challenge of a global pandemic, 2020 has been an invaluable year in cardiology research with numerous important clinical trials published or presented virtually at major international meetings. This article aims to summarise these trials and place them in clinical context.

METHODS

The authors reviewed clinical trials presented at major cardiology conferences during 2020 including the American College of Cardiology, European Association for Percutaneous Cardiovascular Interventions, European Society of Cardiology, Transcatheter Cardiovascular Therapeutics and the American Heart Association. Trials with a broad relevance to the cardiology community and those with potential to change current practice were included.

RESULTS

A total of 87 key cardiology clinical trials were identified for inclusion. New interventional and structural cardiology data included trials evaluating bifurcation percutaneous coronary intervention (PCI) techniques, intravascular ultrasound (IVUS)-guided PCI, instantaneous wave-free (iFR) physiological assessment, new generation stents (DynamX bioadaptor), transcatheter aortic valve implantation (TAVI) in low-risk patients, and percutaneous mitral or tricuspid valve interventions. Preventative cardiology data included new data with proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors (evolocumab and alirocumab), omega-3 supplements, evinacumab and colchicine in the setting of chronic coronary artery disease. Antiplatelet data included trials evaluating both the optimal length of course following PCI and combination of antiplatelet agents and regimes including combination antithrombotic therapies for patients with atrial fibrillation (AF). Heart failure data included the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors (sotagliflozin, empagliflozin and dapagliflozin) and mavacamten in hypertrophic cardiomyopathy. Electrophysiology trials included early rhythm control in AF and screening for AF.

CONCLUSION

This article presents a summary of key clinical cardiology trials during the past year and should be of relevance to both clinicians and cardiology researchers.

Aspirin-free antiplatelet regimens after PCI: insights from the GLOBAL LEADERS trial and beyond

Historically, aspirin has been the primary treatment for the prevention of ischaemic events in patients with coronary artery disease. For patients undergoing percutaneous coronary intervention (PCI) standard treatment has been 12 months of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, followed by aspirin monotherapy; however, DAPT is undeniably associated with an increased risk of bleeding. For over a decade novel P2Y₁₂ inhibitors, which have increased specificity, potency, and efficacy have been available, prompting studies which have tested whether these newer agents can be used in aspirin-free antiplatelet regimens to augment clinical benefits in patients post-PCI. Among these studies, the GLOBAL LEADERS trial is the largest by cohort size, and so far has provided a wealth of evidence in a variety of clinical settings and patient groups. This article summarizes the state-of-the-art evidence obtained from the GLOBAL LEADERS and other trials of aspirin-free strategies.

Dual Antiplatelet Therapy De-escalation Strategies

Dual antiplatelet therapy (DAPT), the combination of aspirin (ASA), and a P2Y₁₂ inhibitor, protects against stent thrombosis and new atherothrombotic events after a stent implantation or an acute coronary syndrome, but exposes patients to an increased risk of bleeding. In most current practices, the P2Y₁₂ inhibitor is stopped at 6 to 12 months and ASA is continued indefinitely. The advent of safer stents, with less risk of stent thrombosis, has challenged this standard of care, however. A number of alternative strategies involving earlier de-escalation of the antiplatelet therapy have therefore been proposed. In these approaches, standard DAPT is switched to a less potent antithrombotic combination at an earlier time-point than recommended by guidelines. Three different de-escalation variations have been tested to date. The first one maintains DAPT but switches from the potent P2Y₁₂ inhibitors ticagrelor or prasugrel to either a lower dose or to clopidogrel, while maintaining ASA. The 2 other approaches involve changing DAPT to a single antiplatelet at some earlier time-point after the percutaneous coronary intervention procedure, by stopping either the P2Y₁₂ inhibitor or ASA. These strategies have all demonstrated some benefit in clinical trials so far, but especially the contribution of ASA in secondary prevention is clearly evolving as its role in increasing bleeding complications while not providing increased ischemic benefit is becoming more and more clear. In contemporary practice, the type and duration of DAPT should now be based on an individualized decision, and the de-escalation strategies, if used wisely, can be added to the existing options.

Current state-of-the-art antiplatelet and anticoagulation therapy in diabetic patients with coronary artery disease

Diabetes mellitus is a complex disease that leads to long-term damage to various organ systems. Among the numerous cardiovascular disease-related complications, thrombotic events frequently occur in patients with diabetes. Although guidelines exist for treating and preventing most diabetes-related co-morbidities, the evidence on antithrombotic therapy in primary and secondary prevention is limited due to the scarcity of randomized trials dedicated to patients with diabetes mellitus. Most of the available data are derived from studies that only included a small proportion of patients with diabetes. The present review provides an overview of the status of knowledge on antiplatelet and anticoagulation therapy in patients with diabetes, focusing on the risk-benefit balance of these therapies and future treatment strategies.

Patient-tailored antithrombotic therapy following percutaneous coronary intervention

Dual antiplatelet therapy has long been the standard of care in preventing coronary and cerebrovascular thrombotic events in patients with chronic coronary syndrome and acute coronary syndrome undergoing percutaneous coronary intervention, but choosing the optimal treatment duration and composition has become a major challenge. Numerous studies have shown that certain patients benefit from either shortened or extended treatment duration. Furthermore, trials evaluating novel antithrombotic strategies, such as P2Y12 inhibitor monotherapy, low-dose factor Xa inhibitors on top of antiplatelet therapy, and platelet function- or genotype-guided (de-)escalation of treatment, have shown promising results. Current guidelines recommend risk stratification for tailoring treatment duration and composition. Although several risk stratification methods evaluating ischaemic and bleeding risk are available to clinicians, such as the use of risk scores, platelet function testing , and genotyping, risk stratification has not been broadly adopted in clinical practice. Multiple risk scores have been developed to determine the optimal treatment duration, but external validation studies have yielded conflicting results in terms of calibration and discrimination and there is limited evidence that their adoption improves clinical outcomes. Likewise, platelet function testing and genotyping can provide useful prognostic insights, but trials evaluating treatment strategies guided by these stratification methods have produced mixed results. This review critically appraises the currently available antithrombotic strategies and provides a viewpoint on the use of different risk stratification methods alongside clinical judgement in current clinical practice.

Ischemic and Bleeding Events of Ticagrelor Monotherapy in Korean Patients With and Without Diabetes Mellitus: Insights From the TICO Trial

Background: Ticagrelor monotherapy after 3 months dual antiplatelet therapy (DAPT) with aspirin and ticagrelor can reduce bleeding without increasing ischemic events after percutaneous coronary intervention (PCI). However, the impact of this approach among the patient with diabetes remains unknown.

Methods: This was a sub-analysis of the Ticagrelor Monotherapy after 3 months in the Patients Treated with New Generation Sirolimus Eluting Stent for Acute Coronary Syndrome (TICO) trial. After successful PCI, the patients were randomly assigned to ticagrelor monotherapy after 3-months DPAT or to ticagrelor-based 12-months DAPT. We compared ischemic events and bleeding events between the patients with diabetes and without diabetes for 12 months. Ischemic events were defined as death, myocardial infarction, ischemic stroke, transient ischemic attack, stent thrombosis, and any revascularizations. Bleeding events were defined according to the Thrombolysis in Myocardial Infarction (TIMI) criteria and Bleeding Academic Research Consortium (BARC) definition.

Results: Between August 2015 and October 2018, 3,056 patients were enrolled in the TICO trial, of which 835 (27.3%) had diabetes mellitus. Diabetes mellitus was associated with all evaluated ischemic and bleeding events. No significant differences in any ischemic events were observed in patients with diabetes between ticagrelor monotherapy after 3-months DAPT and ticagrelor-based 12-months DAPT (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.45–1.52, p = 0.540). In patients with diabetes, the overall incidence of bleeding complications during the 12-months follow-up period did not differ between the two treatment groups (HR 0.83, 95% CI 1.48–1.43, p = 0.505). However, ticagrelor monotherapy was significantly reduced both any TIMI bleeding and BARC three or five bleeding events in diabetes patients in the 3-months landmark analysis, after 3-months DAPT period (HR 0.20, 95% CI 0.07–0.59, p = 0.003).

Conclusion: In diabetic patients, ticagrelor monotherapy showed a lower incidence of bleeding complications after 3-months DAPT period, without increasing ischemic complications, compared with ticagrelor-based 12-months DAPT (ClinicalTrials.gov Identifier: NCT02494895).

Safety and efficacy of P2Y12 inhibitor monotherapy in patients undergoing percutaneous coronary interventions

Introduction: Antiplatelet therapy represents a key strategy for the prevention of thrombotic complications in patients with both acute and chronic coronary syndromes, particularly those undergoing percutaneous coronary intervention (PCI). Nevertheless, dual antiplatelet therapy (DAPT) is associated with a bleeding risk proportionate to its duration. Ever growing appreciation of the prognostic implications associated with bleeding and the development of safer stent platforms over the past years have led to a number of novel antiplatelet treatment strategies being tested among patients undergoing PCI. Areas covered: P2Y₁₂ inhibitor monotherapy after ashort course DAPT has emerged as ableeding reduction strategy to mitigate such risk while still preventing thrombotic complications. In this review we describe the latest evidence regarding the safety and efficacy of P2Y₁₂ inhibitor monotherapy in patients undergoing PCI in different clinical settings. Expert opinion: P2Y₁₂ inhibitor monotherapy after a brief period of DAPT has emerged as an effective approach to reduce the risk of bleeding without any tradeoff in efficacy (i.e., thrombotic complications). This strategy has shown consistent findings in a number of different clinical settings of patients undergoing PCI. Nevertheless, unanswered questions on the ideal patient and the precise P2Y₁₂ monotherapy regimen warrant further investigation.

Antithrombotic Therapy for Atherosclerotic Cardiovascular Disease Risk Mitigation in Patients With Coronary Artery Disease and Diabetes Mellitus

Patients with diabetes mellitus (DM) are characterized by enhanced thrombotic risk attributed to multiple mechanisms including hyperreactive platelets, hypercoagulable status, and endothelial dysfunction. As such, they are more prone to atherosclerotic cardiovascular events than patients without DM, both before and after coronary artery disease (CAD) is established. In patients with DM without established CAD, primary prevention with aspirin is not routinely advocated because of its increased risk of major bleeding that largely offsets its ischemic benefit. In patients with DM with established CAD, secondary prevention with antiplatelet drugs is an asset of pharmacological strategies aimed at reducing the risk of atherosclerotic cardiovascular events and their adverse prognostic consequences. Such antithrombotic strategies include single antiplatelet therapy (eg, with aspirin or a P2Y₁₂ inhibitor), dual antiplatelet therapy (eg, aspirin combined with a P2Y₁₂ inhibitor), and dual-pathway inhibition (eg, aspirin combined with the vascular dose of the direct oral anticoagulant rivaroxaban) for patients with chronic ischemic heart disease, acute coronary syndromes, and those undergoing percutaneous coronary intervention. Because of their increased risk of thrombotic complications, patients with DM commonly achieve enhanced absolute benefit from more potent antithrombotic approaches compared with those without DM, which most often occurs at the expense of increased bleeding. Nevertheless, studies have shown that when excluding individuals at high risk for bleeding, the net clinical benefit favors the use of intensified long-term antithrombotic therapy in patients with DM and CAD. Several studies are ongoing to establish the role of novel antithrombotic strategies and drug formulations in maximizing the net benefit of antithrombotic therapy for patients with DM. The scope of this review article is to provide an overview of current and evolving antithrombotic strategies for primary and secondary prevention of atherosclerotic cardiovascular events in patients with CAD and DM.

Ticagrelor alone vs. ticagrelor plus aspirin following percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndromes: TWILIGHT-ACS

Aims 

The aim of this study was to determine the effect of ticagrelor monotherapy on clinically relevant bleeding and major ischaemic events in relation to clinical presentation with and without non-ST elevation acute coronary syndromes (NSTE-ACS) among patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES).

Methods and results 

We conducted a pre-specified subgroup analysis of The Ticagrelor With Aspirin or Alone in High Risk Patients After Coronary Intervention (TWILIGHT) trial, which enrolled 9006 patients with high-risk features undergoing PCI with DES. After 3 months of dual antiplatelet therapy (DAPT) with ticagrelor plus aspirin, 7119 adherent and event-free patients were randomized in a double-blind manner to ticagrelor plus placebo versus ticagrelor plus aspirin for 12 months. The primary outcome was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding while the composite of all-cause death, myocardial infarction (MI), or stroke was the key secondary outcome. Among patients with NSTE-ACS (n = 4614), ticagrelor monotherapy reduced BARC 2, 3, or 5 bleeding by 53% [3.6% vs. 7.6%; hazard ratio (HR) 0.47; 95% confidence interval (CI) 0.36–0.61; P &lt; 0.001) and in stable patients (n = 2503) by 24% (4.8% vs. 6.2%; HR 0.76; 95% CI 0.54–1.06; P = 0.11; nominal Pint = 0.03). Rates of all-cause death, MI, or stroke among those with (4.3% vs. 4.4%; HR 0.97; 95% CI 0.74–1.28; P = 0.84) and without (3.1% vs. 3.2%; HR 0.96; 95% CI 0.61–1.49; P = 0.85) NSTE-ACS were similar between treatment arms irrespective of clinical presentation (Pint = 0.96).

Conclusion 

Among patients with or without NSTE-ACS who have completed an initial 3-month course of DAPT following PCI with DES, ticagrelor monotherapy reduced clinically meaningful bleeding events without increasing ischaemic risk as compared with ticagrelor plus aspirin. The benefits of ticagrelor monotherapy with respect to bleeding events were more pronounced in patients with NSTE-ACS.

Trial registration

Clinicaltrials.gov identifier: NCT02270242.

Ticagrelor monotherapy in patients with concomitant diabetes mellitus and chronic kidney disease: a post hoc analysis of the GLOBAL LEADERS trial

Background

Patients with both diabetes mellitus (DM) and chronic kidney disease (CKD) are a subpopulation characterized by ultrahigh ischemic and bleeding risk after percutaneous coronary intervention. There are limited data on the impact of ticagrelor monotherapy among these patients.

Methods

In this post hoc analysis of the GLOBAL-LEADERS trial, the treatment effects of the experimental (one-month dual-antiplatelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) versus the reference regimen (12-month DAPT followed by 12-month aspirin alone) were analyzed according to DM/CKD status. The primary endpoint was a composite endpoint of all-cause death or new Q-wave myocardial infarction at 2-years. The patient-oriented composite endpoint (POCE) was defined as the composite of all-cause death, any stroke, site-reported MI and any revascularization, whereas net adverse clinical events (NACE) combined POCE with BARC type 3 or 5 bleeding events.

Results

At 2 years, the DM + /CKD + patients had significantly higher incidences of the primary endpoint (9.5% versus 3.1%, adjusted HR 2.16; 95% CI [1.66–2.80], p < 0.001), BARC type 3 or 5 bleeding events, stroke, site-reported myocardial infraction, all revascularization, POCE, and NACE, compared with the DM-/CKD- patients. Among the DM + /CKD + patients, after adjustment, there were no significant differences in the primary endpoints between the experimental and reference regimen; however, the experimental regimen was associated with lower rates of POCE (20.6% versus 25.9%, HR 0.74; 95% CI [0.55–0.99], p = 0.043, p_interaction = 0.155) and NACE (22.7% versus 28.3%, HR 0.75; 95% CI [0.56–0.99], p = 0.044, p_interaction = 0.310), which was mainly driven by a lower rate of all revascularization, as compared with the reference regimen. The landmark analysis showed that while the experimental and reference regimen had similar rates of all the clinical endpoints during the first year, the experimental regimen was associated with significantly lower rates of POCE (5.8% versus 11.0%, HR 0.49; 95% CI [0.29–0.82], p = 0.007, p_interaction = 0.040) and NACE (5.8% versus 11.2%, HR 0.48; 95% CI [0.29–0.82], p = 0.007, p_interaction = 0.013) in the second year.

Conclusion

Among patients with both DM and CKD, ticagrelor monotherapy was not associated with lower rates of all-cause death or new Q-wave, or major bleeding complications; however, it was associated with lower rates of POCE and NACE. These findings should be interpreted as hypothesis-generating.

Clinical Trial Registration: ClinicalTrials.gov (NCT01813435).

The Role of Aspirin After High-Risk Percutaneous Coronary Intervention: The Ticagrelor with Aspirin or Alone in High-Risk Patients After Coronary Intervention Clinical Trial Experience

Traditionally, aspirin has played a significant role in both primary and secondary prevention of cardiovascular disease. However, emerging antithrombotic regimens with better efficacy and safety have challenged the foundation of aspirin. Aspirin-free strategies consisting of P2Y12 inhibitor monotherapy following percutaneous coronary intervention (PCI) have now been tested in several large randomized controlled trials. In this article, we provide a contemporary overview of these data and suggest an algorithm to inform clinical decision with respect to antiplatelet pharmacotherapy after PCI.

An updated drug profile of ticagrelor with considerations on the treatment of patients with coronary artery disease and diabetes mellitus

INTRODUCTION

Ticagrelor is an antiplatelet agent acting through direct and reversible competitive inhibition of the platelet P2Y₁₂ receptor. While the clinical merits of ticagrelor in patients who experienced an acute coronary syndrome are widely accepted, its role in stable coronary artery disease is less established. Recently, large-scale trials of ticagrelor have been published in this setting, including a trial in patients with diabetes mellitus (DM).

AREAS COVERED

This review aims to inform about recent findings on ticagrelor, by appraising the current body of evidence on its use in different clinical scenarios, particularly in DM, ranging from pharmacology to clinical outcomes and future directions.

EXPERT OPINION

The results of the THEMIS trial, conducted in DM patients with stable coronary artery disease and no prior stroke or myocardial infarction, showed that although ticagrelor in addition to aspirin reduced the risk of ischemic events, this was associated with a parallel increase in bleeding complications. However, patients with history of percutaneous coronary intervention seemed to benefit more from adjunctive ticagrelor therapy. Careful bleeding and ischemic risk stratification remains crucial to define the best antithrombotic strategy for the individual patient.