https://orcid.org/0000-0002-5714-0907
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Giovanna Liuzzo, Carlo Patrono, Weekly Journal Scan: a penULTIMATE frontier for optimal antiplatelet therapy after drug-eluting stenting in acute coronary syndromes?, European Heart Journal, Volume 45, Issue 34, 7 September 2024, Pages 3108–3110, https://doi.org/10.1093/eurheartj/ehae367
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Comment on ‘Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT): a randomised, placebo-controlled, double-blind clinical trial’ published in The Lancet; https://doi.org/10.1016/S0140-6736(24)00473-2.
Comment
In patients with ACS undergoing PCI with DES implantation, 12-month DAPT with aspirin and prasugrel or ticagrelor is the only strategy with a class I recommendation according to 2023 ESC guidelines.2 However, an increased likelihood of bleeding might require adjustments to the duration of DAPT or a different choice of antiplatelet agent.3
Randomized clinical trials and meta-analyses of individual patient data (IPD) have evaluated the efficacy and safety of P2Y12 inhibitor monotherapy after 1–3 months of DAPT. The GLOBAL LEADERS trial of ∼16 000 patients undergoing PCI for stable coronary artery disease (CAD) or ACS found no superiority in terms of death or MI (the primary endpoint) of a strategy involving 1-month DAPT followed by ticagrelor monotherapy over standard 12-month DAPT followed by aspirin after DES implantation.4 Bleeding risk was reduced in the ACS subgroup with 1-month DAPT.5 The TWILIGHT study of selected high-risk patients including ACS showed that after 3 months of DAPT, ticagrelor monotherapy was safer (in terms of BARC 3 or 5 bleeding) and non-inferior in terms of MACE compared to the standard 12-month DAPT.6 The SIDNEY-2 Collaboration IPD meta-analysis, involving over 38 000 patients undergoing complex and non-complex PCI for both stable CAD and ACS, supported P2Y12 inhibitor monotherapy to reduce BARC type 3 or 5 bleeding events, and demonstrated its non-inferiority for MACE compared to standard DAPT, with notable benefits for bleeding in ACS patients7 and those undergoing complex PCI.8 A more recent systematic review and IPD meta-analysis of six randomized trials including ∼26 000 patients undergoing PCI (64% for ACS) found that ticagrelor monotherapy was non-inferior to DAPT for all-cause death, MI, or stroke and superior for major bleeding.9 Although clopidogrel monotherapy was similarly associated with reduced bleeding, it was not non-inferior to DAPT for all-cause death, MI, or stroke.9
