Key result
Long-term ticagrelor reduced the risk of major adverse cardiovascular events in patients with prior myocardial infarction and no history of coronary stenting (HR 0.82).
Why the study?
Does long-term ticagrelor reduce MACE in patients with prior myocardial infarction regardless of prior coronary stenting?
RCT (n=21,162)
Does long-term ticagrelor reduce MACE in patients with prior myocardial infarction regardless of prior coronary stenting?
Hazard Ratio: 0.82
Long-term ticagrelor reduces thrombotic events in patients with prior myocardial infarction regardless of whether they had prior coronary stenting.
For the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts. Coronary artery disease has many faces: 1 it may accompany non-obstructive or obstructive plaques causing ischaemia or even angina upon exercise2 or at rest in the context of an acute event, or be silent after percutaneous coronary intervention (PCI) or bypass surgery.3,4 Finally, dysfunction of the coronary microcirculation5 may add complexity to the syndrome. Depending on the presence of either or several of such conditions, different management strategies must be considered. However, under all conditions, secondary prevention of cardiovascular risk factors6–8 and dual antiplatelet therapy (DAPT;9 as outlined in the ESC Guidelines) must be considered. The latter aspect is addressed in the article ‘Long-term ticagrelor for secondary prevention in patients with prior myocardial infarction and no history of coronary stenting: insights from PEGASUS-TIMI 54’ by Remo Furtado and colleagues from the Universidade de Sao Paulo in Brazil. The authors remind us that PEGASUS-TIMI 54 demonstrated that in patients with prior myocardial infarction, long-term DAPT with aspirin and ticagrelor reduced the risk of major adverse cardiovascular events (MACE), with an acceptable increase in bleeding.10 While much of the discussion around prolonged DAPT has been focused on stented patients, patients with prior myocardial infarction without prior coronary stenting comprise a clinically unaddressed subgroup. A total of 4199 of the 21 162 patients had no history of coronary stenting. In the placebo arm, they had a higher baseline risk of MACE (i.e. 13.24% vs. 7.98% with an adjusted hazard ratio of 1.41; Figure 1). The relative risk reduction in MACE with ticagrelor was similar in patients without (hazard ratio 0.82) and with prior stenting (hazard ratio 0.85). Thus, long-term ticagrelor reduces thrombotic events in patients with prior infarction regardless of whether they had prior coronary stenting, highlighting the benefits of DAPT in preventing spontaneous atherothrombotic events. The implications of these findings are further assessed in an Editorial by Robert Welsh from the Mazankowski Alberta Heart Institute in Edmonton, Canada.11
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Thomas F. Lüscher (2020) conducted an RCT in Prior myocardial infarction (n=21,162). Ticagrelor vs. Placebo was evaluated on Major adverse cardiovascular events (MACE) (HR 0.82). Long-term ticagrelor reduced the risk of major adverse cardiovascular events in patients with prior myocardial infarction and no history of coronary stenting (HR 0.82).
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