A correction has been published: European Heart Journal, ehaa895, https://doi.org/10.1093/eurheartj/ehaa895

2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization

Importance Discontinuing aspirin after short-term dual antiplatelet therapy (DAPT) was evaluated as a bleeding reduction strategy. However, the strategy of ticagrelor monotherapy has not been exclusively evaluated in patients with acute coronary syndromes (ACS). Objective To determine whether switching to ticagrelor monotherapy after 3 months of DAPT reduces net adverse clinical events compared with ticagrelor-based 12-month DAPT in patients with ACS treated with drug-eluting stents. Design, Setting, and Participants A randomized multicenter trial was conducted in 3056 patients with ACS treated with drug-eluting stents between August 2015 and October 2018 at 38 centers in South Korea. Follow-up was completed in October 2019. Interventions Patients were randomized to receive ticagrelor monotherapy (90 mg twice daily) after 3-month DAPT (n = 1527) or ticagrelor-based 12-month DAPT (n = 1529). Main Outcomes and Measures The primary outcome was a 1-year net adverse clinical event, defined as a composite of major bleeding and adverse cardiac and cerebrovascular events (death, myocardial infarction, stent thrombosis, stroke, or target-vessel revascularization). Prespecified secondary outcomes included major bleeding and major adverse cardiac and cerebrovascular events. Results Among 3056 patients who were randomized (mean age, 61 years; 628 women [20%]; 36% ST-elevation myocardial infarction), 2978 patients (97.4%) completed the trial. The primary outcome occurred in 59 patients (3.9%) receiving ticagrelor monotherapy after 3-month DAPT and in 89 patients (5.9%) receiving ticagrelor-based 12-month DAPT (absolute difference, −1.98% [95% CI, −3.50% to −0.45%]; hazard ratio [HR], 0.66 [95% CI, 0.48 to 0.92];P = .01). Of 10 prespecified secondary outcomes, 8 showed no significant difference. Major bleeding occurred in 1.7% of patients with ticagrelor monotherapy after 3-month DAPT and in 3.0% of patients with ticagrelor-based 12-month DAPT (HR, 0.56 [95% CI, 0.34 to 0.91];P = .02). The incidence of major adverse cardiac and cerebrovascular events was not significantly different between the ticagrelor monotherapy after 3-month DAPT group (2.3%) vs the ticagrelor-based 12-month DAPT group (3.4%) (HR, 0.69 [95% CI, 0.45 to 1.06];P = .09). Conclusions and Relevance Among patients with acute coronary syndromes treated with drug-eluting stents, ticagrelor monotherapy after 3 months of dual antiplatelet therapy, compared with ticagrelor-based 12-month dual antiplatelet therapy, resulted in a modest but statistically significant reduction in a composite outcome of major bleeding and cardiovascular events at 1 year. The study population and lower than expected event rates should be considered in interpreting the trial. Trial Registration ClinicalTrials.gov Identifier:NCT02494895

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Effect of Ticagrelor Monotherapy vs Ticagrelor With Aspirin on Major Bleeding and Cardiovascular Events in Patients With Acute Coronary Syndrome: The TICO Randomized Clinical Trial.

In 2019, the Japanese Circulation Society published 2 guidelines in the field of coronary artery disease (CAD): (1) a guideline for acute coronary syndrome (ACS) that integrated guidelines for ST-elevation acute myocardial infarction, non-ST-elevation ACS (NSTE-ACS), and secondary prevention for myocardial infarction, and (2) guideline for revascularization of stable CAD by coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).1,2 These guidelines were substantially revised to reflect the latest evidence, but after publication of the revised guidelines, important new evidence was reported and new concepts have been established. In particular, important evidence has accumulated about antithrombotic therapy after PCI that is directly related to daily clinical practice. Therefore, we are providing an update focusing on this area without waiting for the next revision of the entire guideline. Because the risk of bleeding events is higher and the risk of thrombotic events is lower in East Asian patients, the risk/benefit balance between thrombosis and bleeding in East Asian patients is suggested to be different from that in other populations.3,4 In fact, lowerdose antithrombotic therapy is recommended in East Asia compared with Western countries, and a lower target value for the international standardized ratio of prothrombin time (PT-INR) is also recommended for elderly patients. For these reasons, extrapolation of evidence from the USA and Europe requires careful consideration, and verification by assessment in clinical practice in Japan is always necessary. In this regard, the present update includes clinical trials performed in Japan and the data from these trials played a major role in the preparation of the guideline update. This guideline update also covers patients who are managed conservatively with drug therapy, in addition to those who have undergone reperfusion therapy and

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JCS 2020 Guideline Focused Update on Antithrombotic Therapy in Patients With Coronary Artery Disease

Background Monotherapy with a P2Y12 inhibitor after a minimum period of dual antiplatelet therapy is an emerging approach to reduce the risk of bleeding after percutaneous coronary interve...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1908419?listPDF=true

Jin Y Cha

Papers

Ticagrelor with or without Aspirin in High-Risk Patients after PCI