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1. Clinically relevant bleeding was significantly lower with ticagrelor monotherapy than in the ticagrelor plus aspirin group.

2. Major cardiovascular and cerebrovascular events were comparable in both groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Dual antiplatelet therapy (DAPT) is the current standard of care for acute coronary syndrome (ACS) following percutaneous coronary intervention (PCI). However, data on single antiplatelet therapy with a potent P2Y12 inhibitor is lacking. This randomized trial aimed to assess whether ticagrelor alone, versus ticagrelor plus aspirin, reduces bleeding without increasing major adverse cardiovascular or cerebrovascular events (MACCE). The primary outcome was clinically relevant bleeding, defined as Bleeding Academic Research Consortium types 2, 3, or 5, while the key secondary outcome was MACCE. According to the results, ticagrelor monotherapy reduced clinically significant bleeding risk without increasing MACCE compared to ticagrelor plus aspirin. Although this study was well done, it was limited by its focus on a specific patient population and short follow-up duration.

Click to read the study in The Lancet

Relevant Reading: Ticagrelor with or without Aspirin in High-Risk Patients after PCI

In-depth [randomized controlled trial]: Between Aug 20, 2019, and Oct 27, 2022, 3710 patients were screened across 58 centers in China, Italy, Pakistan, and the UK. Included were patients aged ≥ 18 years with ACS who had no major ischemic or bleeding events after 1-month treatment with DAPT. Altogether, 3400 patients (1700 each in ticagrelor plus aspirin and ticagrelor plus placebo groups) were included in the final analysis. The primary outcome of clinically relevant bleeding was significantly lower in the ticagrelor alone group than in ticagrelor plus aspirin (2.1% vs. 4.6%, hazard ratio [HR] 0.45, 95% confidence interval [CI] 0.30-0.66, p<0.0001). Both groups were comparable with regard to MACCE (3.6% in ticagrelor alone vs. 3.6% in ticagrelor plus placebo, HR 0.98, 95% CI 0.69-1.39, p<0.0001). Findings from this study suggest that ticagrelor monotherapy after 1 month of DAPT reduces bleeding without increasing MACCE in patients with recent PCI following ACS.

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