Antiplatelet Strategies Following PCI: A Review of Trials Informing Current and Future Therapies

Ticagrelor monotherapy versus ticagrelor plus aspirin in patients with chronic coronary syndrome and high ischaemic risk: a post hoc analysis of the TWILIGHT trial

BACKGROUND

Short dual antiplatelet therapy (DAPT) followed by ticagrelor monotherapy may be a valuable therapeutic option for patients with chronic coronary syndrome (CCS) and high ischaemic risk (HIR) undergoing percutaneous coronary intervention (PCI).

AIMS

We aimed to compare ticagrelor monotherapy with ticagrelor-based DAPT in CCS patients with and without HIR undergoing PCI.

METHODS

The present analysis included the CCS cohort of the TWILIGHT trial, which randomised PCI patients to ticagrelor alone or in combination with aspirin for 12 months after 3 months of ticagrelor-based DAPT. Patients were stratified into HIR and non-HIR based on the 2019 European Society of Cardiology (ESC) CCS guidelines definition. Outcomes of interest were major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction or stroke, and Bleeding Academic Research Consortium (BARC) Type 2-5 bleeding at 1 year.

RESULTS

Of the 2,503 CCS patients who underwent randomisation, the ESC definition classified 1,264 (50.5%) as HIR and 1,239 (49.5%) as non-HIR. HIR patients displayed a higher risk of MACCE (3.9% vs 2.3%; p=0.015) and similar rates of BARC Type 2-5 bleeding (5.1% vs 5.7%; p=0.455) as compared to non-HIR patients. Ticagrelor monotherapy and ticagrelor-based DAPT were associated with similar risks of MACCE (HIR: 4.0% vs 3.8%, hazard ratio [HR] 1.06, 95% confidence interval [CI]: 0.60-1.85; non-HIR: 2.1% vs 2.6%, HR 0.80, 95% CI: 0.38-1.66, pinteraction=0.553) and bleeding (HIR: 4.7% vs 5.7%, HR 0.82, 95% CI: 0.50-1.33; non-HIR: 4.9% vs 6.7%, HR 0.71, 95% CI: 0.44-1.14; pinteraction=0.684) in both the HIR and non-HIR groups.

CONCLUSIONS

In a post hoc analysis of the TWILIGHT trial that included CCS patients undergoing PCI, ticagrelor monotherapy after 3 months of DAPT appeared to be safe and was not associated with increased risks of ischaemic or bleeding events, regardless of baseline HIR status, compared with standard ticagrelor-based DAPT. These findings suggest the potential to expand guideline recommendations for ticagrelor monotherapy in CCS.

Potent P2Y12 Inhibitors vs Clopidogrel in Cancer Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Patients with cancer undergoing percutaneous coronary intervention (PCI) experience a higher risk of both ischemic and bleeding events. The aim of this study was to assess ischemic and bleeding risks after PCI in cancer patients treated with potent P2Y12 inhibitors (P2Y12i; prasugrel and ticagrelor) compared with clopidogrel.

METHODS

Consecutive patients with cancer undergoing PCI at a tertiary center between 2012 and 2022 and discharged on P2Y12i were included in this study. Propensity score covariate adjustment was used to account for baseline differences between patients treated with potent P2Y12i and clopidogrel. Key clinical endpoints included major adverse cardiac and cerebrovascular events (MACCEs---composite of death, myocardial infarction, or stroke) and major bleeding.

RESULTS

Of the 1702 included patients, 373 (21.9%) were treated with potent P2Y12i and 1329 (78.1%) with clopidogrel. Factors associated with potent P2Y12i use were acute coronary syndrome presentation and lesion length, whereas clopidogrel use was associated with active cancer status, thrombocytopenia, older age, and femoral access. MACCEs at 1 year occurred in 3.5% of patients treated with potent P2Y12i vs 6.8% of those receiving clopidogrel (log-rank test, P = 0.035; adjusted hazard ratio [adj HR] 0.53, 95% confidence interval [CI] 0.26-1.10), but no differences in bleeding risk were detected (5.5% vs 7.0%, adj HR 0.92, 95% CI 0.53-1.60). The reduction in MACCEs was significant in patients with remission but not active cancer (Pinteraction = 0.011).

CONCLUSIONS

Among cancer patients undergoing PCI, potent P2Y12i use was associated with similar bleeding risk and lower incidence of ischemic events compared with clopidogrel, but with no significant difference after propensity score adjustment.

Fractional flow reserve-guided complete revascularization versus culprit-only percutaneous coronary intervention in patients with myocardial infarction: A meta-analysis of randomized controlled trials

INTRODUCTION

The optimal revascularization strategy for patients with myocardial infarction (MI) and multivessel coronary artery disease (CAD) remains an area of research and debate. Fractional flow reserve (FFR)-guided complete revascularization (CR) by percutaneous coronary intervention (PCI) has emerged as an alternative to traditional culprit-only PCI.

OBJECTIVE

To investigate the outcomes of FFR-guided CR versus culprit-only PCI in patients with MI and multivessel CAD.

METHODS

We systematically searched PubMed, Scopus and Cochrane Central databases for randomized controlled trials (RCTs) comparing FFR-guided CR versus culprit-only PCI in MI patients with multivessel CAD. Outcomes included a composite of all-cause death, MI, stroke and repeat revascularization, these individual outcomes, cardiac death, stent thrombosis (definite or probable), and contrast-induced acute kidney injury (CIAKI). Random effects models were used to generate risk ratios (RRs) with 95 % confidence intervals (CIs).

RESULT

The search identified 5 RCTs including 4618 patients with a median follow-up duration of 3 years. Compared with culprit-only PCI, FFR-guided CR was associated with less composite adverse events (RR 0.73; 95%CI 0.57-0.92; p = 0.009), cardiac death (RR 0.73; 95%CI 0.55-0.97; p = 0.03), and repeat revascularization (RR 0.61; 95%CI 0.44-0.84; p = 0.003). Both strategies were similar in terms of all-cause death, MI, stroke, stent thrombosis, and CIAKI.

CONCLUSION

FFR-guided complete revascularization appears to be superior to culprit-only PCI in reducing composite adverse events, cardiac death, and the need for repeat revascularization in patients with MI and multivessel CAD without a significant impact on recurrent myocardial infarction rates.

SOCIAL MEDIA ABSTRACT

4618-patient meta-analysis: in MI w/ multivessel #CAD, #FFR-guided complete revascularization yields less composite adverse events, cardiac death & repeat revascularization than culprit-only #PCI.

"Very" Very Late Stent Thrombosis: The Occurrence of Thrombosis 12.3 Years After Paclitaxel-Eluting Stent Implantation

Very late stent thrombosis (VLST) refers to stent thrombosis occurring beyond one year after coronary intervention. "Very" very or extremely late stent thrombosis (VVLST), occurring after five years of drug-eluting stent (DES) implantation, is extremely rare. We report a case of a 60-year-old male patient with ST-elevation myocardial infarction (STEMI) due to in-stent thrombosis 12.3 years after first-generation DES implantation; we also engage in a brief discussion of its pathogenesis and prevention.