De-escalating DAPT to ticagrelor monotherapy reduces bleeding in ACS patients

De-escalation of dual antiplatelet therapy (DAPT) to ticagrelor monotherapy results in a decreased risk for major bleeding compared with standard DAPT among patients with acute coronary syndrome (ACS) undergoing drug-eluting stent (DES) implantation, reports a study. 

In addition, de-escalating DAPT does not lead to an increase in ischaemic events, regardless of ACS type.

A team of investigators searched the databases of PubMed, Embase, Scopus, and ClinicalTrials.gov from inception to 12 December 2024 for randomized controlled trials (RCTs) comparing de-escalating DAPT to ticagrelor monotherapy with ticagrelor-based standard DAPT for 12 months, particularly in patients with ACS undergoing DES implantation.

Ischaemic (composite of death, nonprocedural [spontaneous] myocardial infarction, or stroke) and bleeding outcomes (Bleeding Academic Research Consortium types 3 or 5 bleeding) served as coprimary endpoints of this study.

Three RCTs (ie, TICO, T-PASS, and ULTIMATE-DAPT), including a total of 9,130 patients with ACS, met the eligibility criteria. Of the patients, 3,132 had ST-segment elevation myocardial infarction (STEMI), 3,023 had non-STEMI, and 2,975 had unstable angina.

The rate of the primary ischaemic endpoint did not significantly differ between the ticagrelor monotherapy and standard DAPT groups (1.7 percent vs 2.1 percent; hazard ratio [HR], 0.85, 95 percent confidence interval [CI], 0.63–1.16).

On the other hand, the rate of the primary bleeding endpoint was lower in the ticagrelor monotherapy group than the standard DAPT group (0.8 percent vs 2.5 percent; HR, 0.30, 95 percent CI, 0.21–0.45).

"These findings were consistent in patients with STEMI, NSTEMI, and unstable angina,” the investigators said.

This study was limited by the noninclusion of other de-escalation strategies for modulating antiplatelet therapy.