Key result
Ticagrelor monotherapy reduces major bleeding ~56% vs. standard DAPT without increasing MACCE.
Why the study?
Prolonged DAPT after PCI for ACS increases major bleeding risk, and whether early aspirin discontinuation with ticagrelor monotherapy maintains ischaemic protection while reducing bleeding required updated evaluation in contemporary PCI populations.
Does early aspirin withdrawal followed by ticagrelor monotherapy after short-term DAPT reduce bleeding while maintaining ischaemic protection compared to continued standard DAPT in patients undergoing PCI?
Meta-Analysis (n=19,755)
Does early aspirin withdrawal followed by ticagrelor monotherapy after short-term DAPT reduce bleeding while maintaining ischaemic protection compared to continued standard DAPT in patients undergoing PCI?
Early de-escalation to ticagrelor monotherapy after 2 weeks to 3 months of DAPT post-PCI more than halves the risk of major bleeding without increasing mortality or ischaemic events in predominantly ACS patients.
Supports ticagrelor monotherapy after short DAPT post-PCI; reinforces consensus for de-escalation to minimize bleeding without ischemic compromise.
Background/Introduction Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the standard treatment after percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS). However, prolonged DAPT increases major bleeding risk. Early aspirin discontinuation with ticagrelor monotherapy may reduce bleeding while maintaining ischaemic protection. Purpose To evaluate the efficacy and safety of early aspirin withdrawal followed by ticagrelor monotherapy compared with standard DAPT in contemporary PCI populations, specifically focusing on the high-risk ACS cohort. Methods A systematic review and meta-analysis of randomised controlled trials (RCTs) comparing ticagrelor monotherapy after short-term DAPT (2 weeks–3 months) versus continued DAPT was conducted. Five trials (T-PASS, TICO, TWILIGHT, ULTIMATE-DAPT, and NEO-MINDSET) were identified, totaling 19,755 patients (80–90% with ACS). Risk ratios (RR) with 95% confidence intervals (CI) were pooled using random-effects models for ischaemic and bleeding outcomes. Result Ticagrelor monotherapy significantly reduced all bleeding (RR 0.54; 95% CI 0.47–0.62; P<0.00001) and major bleeding (RR 0.44; 95% CI 0.36–0.55; P<0.00001). There were no significant differences in all-cause mortality (RR 0.95; 95% CI 0.75–1.20; P=0.42), cardiovascular mortality (RR 0.86; 95% CI 0.63–1.17; P=0.33), or major adverse cardiovascular and cerebrovascular events (RR 0.95; 95% CI 0.76–1.18; P=0.63). Individual ischaemic endpoints including myocardial infarction (RR 1.10; 95% CI 0.85–1.42), stent thrombosis (RR 1.15; 95% CI 0.68–1.95), and stroke (RR 1.03; 95% CI 0.70–1.53) were similar between groups. Conclusion In patients undergoing PCI, predominantly for ACS, early de-escalation to ticagrelor monotherapy after a short course of DAPT significantly reduces major bleeding without increasing the risk of mortality or ischaemic events. These findings support ticagrelor monotherapy as a viable alternative for patients who remain event-free in the early post-PCI period.1.
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Ferreira et al. (2026) conducted a meta-analysis in Percutaneous coronary intervention (predominantly for acute coronary syndromes) (n=19,755). Ticagrelor monotherapy after short-term DAPT (2 weeks-3 months) vs. Continued standard dual antiplatelet therapy (DAPT) was evaluated on Major bleeding (RR 0.44, 95% CI 0.36-0.55, p=<0.00001). Ticagrelor monotherapy after short-term DAPT reduced major bleeding (RR 0.44; 95% CI 0.36-0.55; P<0.00001) without increasing MACCE (RR 0.95; 95% CI 0.76-1.18) vs standard DAPT.
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