Ticagrelor with and without aspirin in patients with a prior coronary artery bypass graft undergoing percutaneous coronary intervention: the TWILIGHT-CABG study

Gennaro Sardella, Frans J. Beerkens, George Dangas, Davide Cao, Usman Baber, Samantha Sartori, David J. Cohen, Carlo Briguori, Robert Gil, Johny Nicolas, Zhongjie Zhang, Dariusz Dudek, Vijay Kunadian, Ran Kornowski, Giora Weisz, Bimmer Claessen, Steven O. Marx, Javier Escaned, Kurt Huber, Timothy CollierDavid J. Moliterno, E. Magnus Ohman, Mitchell W. Krucoff, Adnan Kastrati, Phillippe Gabriel Steg, Dominick J. Angiolillo, Shamir R. Mehta, Richard Shlofmitz, Samin Sharma, Stuart Pocock, Charles Michael Gibson, Roxana Mehran

Research output: Contribution to journalArticlepeer-review

4 Scopus citations

Abstract

Background: Prior coronary artery bypass graft surgery (CABG) patients undergoing percutaneous coronary intervention (PCI) are often older and present with multiple comorbidities. Ticagrelor monotherapy after a short course of dual antiplatelet therapy (DAPT) has emerged as an effective bleeding-avoidance strategy among high-risk patients. Aims: We aimed to examine the effects of ticagrelor with or without aspirin in prior CABG patients undergoing PCI within the TWILIGHT trial. Methods: After 3 months of ticagrelor plus aspirin, patients were randomised to either aspirin or placebo, in addition to ticagrelor, for 12 months and compared by prior CABG status. The primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding. The key secondary endpoint was all-cause death, myocardial infarction (MI), or stroke. Results: Out of 7,119 patients, a total of 703 (10.8%) patients had prior CABG within the randomised cohort. Prior CABG patients had more comorbidities and a higher incidence of BARC type 2, 3, or 5 bleeding and death, MI or stroke at 1 year after randomisation, compared with patients without prior CABG. Ticagrelor monotherapy was associated with significantly less BARC 2, 3, or 5 bleeding among prior CABG patients compared with DAPT (4.9% vs 9.6%, hazard ratio [HR] 0.50, 95% confidence interval [CI]: 0.28 to 0.90; pinteraction=0.676) and similar rates of death, MI or stroke (10.0% vs 8.7%, HR 1.14, 95% CI: 0.70 to 1.87; pinteraction=0.484). When comparing target vessel type, treatment effects were consistent among graft- and native-vessel interventions. Conclusions: In high-risk patients with prior CABG, ticagrelor monotherapy reduced bleeding without compromising ischaemic outcomes compared with ticagrelor plus aspirin.

Original languageEnglish
Pages (from-to)E897-E909
JournalEuroIntervention
Volume18
Issue number11
DOIs
StatePublished - Dec 2022

Keywords

  • adjunctive pharmacotherapy
  • bleeding
  • clinical research
  • prior CABG

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