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

Background: The role of transitioning from short dual antiplatelet therapy (DAPT) to potent P2Y12 inhibitor monotherapy in patients with acute coronary syndrome (ACS) undergoing drug-eluting stent (DES) implantation remains inconclusive. Purpose: To compare the effects of de-escalating DAPT to ticagrelor monotherapy versus standard DAPT from randomized clinical trials in patients with ACS. Data Sources: PubMed, EMBASE, Scopus, and ClinicalTrials.gov from inception to 12 December 2024. Study Selection: Randomized clinical trials comparing de-escalating DAPT to ticagrelor monotherapy versus ticagrelor-based standard DAPT for 12 months, specifically in patients with ACS undergoing DES implantation. Data Extraction: The coprimary end points were an ischemic end point (composite of death, nonprocedural [spontaneous] myocardial infarction, or stroke) and a bleeding end point (Bleeding Academic Research Consortium types 3 or 5 bleeding). Data Synthesis: Individual patient data were obtained from 3 trials (TICO [Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome], T-PASS [Ticagrelor Monotherapy in Patients Treated With New-Generation Drug-Eluting Stents for Acute Coronary Syndrome], and ULTIMATE-DAPT [Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes]), including 9130 randomized patients with ACS; 3132 had ST-segment elevation myocardial infarction (STEMI), 3023 had non-STEMI (NSTEMI), and 2975 had unstable angina. The rate of the primary ischemic end point was not different between the ticagrelor monotherapy and standard DAPT groups (1.7% vs. 2.1%; hazard ratio [HR], 0.85 [95% CI, 0.63 to 1.16]). The rate of the primary bleeding end point was lower in the ticagrelor monotherapy group (0.8% vs. 2.5%; HR, 0.30 [CI, 0.21 to 0.45]). These findings were consistent in patients with STEMI, NSTEMI, and unstable angina. Limitation: Other de-escalation strategies for modulating antiplatelet therapy were not included. Conclusion: In patients with ACS undergoing DES implantation, de-escalating DAPT to ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without an increase in ischemic events, regardless of the type of ACS.