De-escalating antiplatelet therapy to ticagrelor monotherapy appears to lower risk of bleeding in stented patients

In patients with ACS (acute coronary syndrome) who have undergone DES (drug-eluting stent) implantation, de-escalating DAPT (dual antiplatelet therapy) to ticagrelor monotherapy resulted in a lower risk for major bleeding compared with standard DAPT, and without an increase in ischemic events.

Researchers reported these findings on February 17, 2025 in the Annals of Internal  Medicine.

As background, the authors noted, “Current guidelines recommend ACS patients undergoing DES implementation receive 12 months of DAPT with aspirin and a P2Y12 inhibitor, however, prolonged use of DAPT carries an increased risk of bleeding complications. The researchers aimed to demonstrate the efficacy and safety of de-escalating DAPT to ticagrelor monotherapy on bleeding ischemic events.”

In this meta-analysis, the investigators identified and extracted data from 3 relevant, randomized clinical trials comparing de-escalating DAPT to ticagrelor monotherapy versus ticagrelor-based standard DAPT for 12 months, and specifically in patients with ACS undergoing DES implantation.

Among 9,130 enrolled subjects with ACS, 3,132 had ST-segment elevation myocardial infarction (STEMI), 3,023 had non-STEMI (NSTEMI) and 2,975 had unstable angina.

The co-primary end points were an ischemic end point (composite of death, non-proce-dural/procedural myocardial infarction, or stroke) and a bleeding end point (Bleeding Academic Research Consortium types 3 or 5 bleeding).

The researchers reported that the rate of the primary ischemic endpoint was not different between the ticagrelor monotherapy and standard DAPT groups (1.7% vs. 2.1%).

However, the rate of the primary bleeding end point was lower in the ticagrelor monotherapy group (0.8% vs. 2.5%.)

“The findings were consistent in patients with STEMI, NSTEMI, and unstable angina,” they said.

The authors concluded, “The researchers found that compared with standard DAPT, de-escalating DAPT to ticagrelor monotherapy was associated with a lower risk for major bleeding without increasing the risk for ischemic events. These effects were consistent across various subgroups, including different ACS types. The findings suggest that de-escalating DAPT to ticagrelor monotherapy in patients with ACS undergoing DES implantation could be a feasible treatment option to avoid aspirin-associated major bleeding.”