Abbreviated ticagrelor based dual antiplatelet therapy in acute coronary syndrome: A systematic review and meta-analysis

Background: Few randomized clinical trials have evaluated the safety and efficacy of abbreviated ticagrelor based dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS); however, these trials were underpowered to detect differences in hard clinical outcomes.

Methods: A systematic search of MEDLINE, Cochrane, and Scopus databases was performed through June 2024, for trials that compared abbreviated (≤3-months) versus standard 12-months ticagrelor based DAPT in ACS. The primary endpoint was all-cause mortality. Secondary endpoints included cardiovascular death, myocardial infarction, stent thrombosis, ischemic stroke, and major bleeding. Endpoints were measured at 12-months after DAPT initiation. Data were pooled using random-effects model. Effect measure utilized was risk ratio (RR). Heterogeneity was assessed via Chi-squared and Higgin's I² test. RevMan 5.0 (Cochrane Collaboration, Oxford, United Kingdom) was utilized to perform statistical analysis.

Results: Five trials were included in this analysis with 21,407 patients assessed. ULTIMATE-DAPT, T-PASS, and GLOBAL LEADERS-ACS assessed 1-month DAPT duration while TICO and TWILIGHT-ACS assessed 3-months DAPT duration. The average age was 62.7 years and 22.7 % were women. ACS presentations included non-ST elevation myocardial infarction (40.1 %), unstable angina (35.2 %), and ST-segment elevation myocardial infarction (31.5 %). Abbreviated ticagrelor based DAPT was associated with lower risk of all-cause mortality (RR 0.78; 95 % Confidence Interval (CI) 0.62-0.98, I² = 0 %) compared with standard duration DAPT. There was no difference between groups in cardiovascular death (RR 0.65; 95 % CI 0.41-1.03, I² = 0 %), myocardial infarction (RR 1.04; 95 % CI 0.85-1.27, I² = 0 %), stent thrombosis (RR 0.97; 95 % CI 0.64-1.45, I² = 0 %), or ischemic stroke (RR 0.90; 95 % CI 0.62-1.30, I² = 0 %). Abbreviated DAPT was associated with lower risk of major bleeding (RR 0.50; 95 % CI 0.38-0.66, I² = 46 %).

Conclusion: Our analysis includes the totality of randomized data evaluating the merits of abbreviated ticagrelor based DAPT after ACS. The salient study finding was the observed reduced risk of all-cause mortality and major bleeding with abbreviated DAPT approach.