Short dual antiplatelet therapy after PCI with Resolute Onyx drug-eluting stents in high bleeding risk patients: One-year outcomes from a South Asian cohort

Background: The optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) in patients with high bleeding risk (HBR) remains unclear. This study evaluated the safety and efficacy of a shortened DAPT strategy (3-month DAPT followed by ticagrelor monotherapy) in patients with HBR receiving Resolute Onyx zotarolimus-eluting stents (ZES). Methods: This retrospective observational study was conducted at the Yashoda Hospitals in Hyderabad. A total of 150 HBR patients who underwent PCI with Resolute Onyx ZES between June 2023 and June 2024 were included in the study. All patients received DAPT (aspirin 75 mg + ticagrelor 90 mg BID) for three months, followed by ticagrelor monotherapy for nine months. The primary outcome was a composite of cardiac death or MI from three months to one year. The secondary endpoints included stent thrombosis, target lesion failure (TLF), target lesion revascularization (TLR), stroke, and bleeding events (BARC classification). Results: The mean age was 75.5 years, and 42.3 % were female. Diabetes was observed in 33.5 % of patients, prior revascularization in 46.4 %, and acute coronary syndrome in 58.3 %. Most lesions were calcified (60.8 %) or complex (88.2 % B2/C lesions). The patients met an average of 1.9 HBR criteria, and 54.6 % met at least two criteria. The primary composite endpoint occurred in 5.7 % of the patients (cardiac death-2.3 %; MI-3.4 %). Definite/probable stent thrombosis occurred in 0.3 %, TLF in 3.0 %, clinically driven TLR in 1.7 %, stroke in 0.6 %, and BARC 1-3 bleeding in 2.1 %. No BARC 3-5 bleeding events were recorded. Conclusion: In this real-world HBR cohort treated with Resolute Onyx ZES, a strategy of 3-month DAPT followed by ticagrelor monotherapy was associated with low rates of ischemic events and the absence of major bleeding at one year. These findings suggest a favorable safety-efficacy balance for DAPT de-escalation in carefully selected patients; however, this requires confirmation in larger, prospective studies.