De-escalating Dual Antiplatelet Therapy to Ticagrelor Monotherapy in Acute Coronary Syndrome : A Systematic Review and Individual Patient Data Meta-analysis of Randomized Clinical Trials.

Summary

Across 9,130 ACS patients in three RCTs, ticagrelor monotherapy after short DAPT reduced major bleeding (BARC 3/5; HR 0.30) without increasing ischemic events (HR 0.85) compared with 12 months of ticagrelor-based DAPT. Benefits were consistent across STEMI, NSTEMI, and unstable angina.

Key Findings

• Individual patient data from 3 RCTs (TICO, T-PASS, ULTIMATE-DAPT) totaling 9,130 ACS patients were analyzed.
• Primary ischemic outcome rates were similar with ticagrelor monotherapy vs. standard DAPT (1.7% vs 2.1%; HR 0.85, 95% CI 0.63–1.16).
• Major bleeding (BARC 3/5) was significantly lower with ticagrelor monotherapy (0.8% vs 2.5%; HR 0.30, 95% CI 0.21–0.45).
• Effects were consistent across STEMI, NSTEMI, and unstable angina subgroups.
• PROSPERO-registered analysis; no external funding reported.

Clinical Implications

Clinicians can consider early transition to ticagrelor monotherapy after a short DAPT course in ACS patients post-DES to reduce major bleeding risk without compromising ischemic protection, tailoring duration to patient risk.

Limitations

• Only ticagrelor-based de-escalation was assessed; other P2Y12 strategies not included.
• Trials largely conducted in East Asian populations, potentially limiting global generalizability.

Future Directions

Head-to-head comparisons of alternative de-escalation strategies, incorporation of bleeding/ischemia risk scores for individualized DAPT duration, and validation across diverse global populations.