Bleeding and Ischemic Outcomes With Ticagrelor Monotherapy According to Body Mass Index

Vijay Kunadian, Usman Baber, Carlo A. Pivato, Davide Cao, George Dangas, Samantha Sartori, Zhongjie Zhang, Dominick J. Angiolillo, Carlo Briguori, David J. Cohen, Timothy Collier, Dariusz Dudek, Michael Gibson, Robert Gil, Kurt Huber, Upendra Kaul, Ran Kornowski, Mitchell W. Krucoff, Payam Dehghani, Shamir MehtaDavid J. Moliterno, E. Magnus Ohman, Javier Escaned, Gennaro Sardella, Samin K. Sharma, Richard Shlofmitz, Giora Weisz, Bernhard Witzenbichler, Vladimír Džavík, Paul Gurbel, Christian W. Hamm, Timothy Henry, Adnan Kastrati, Steven O. Marx, Keith Oldroyd, P. Gabriel Steg, Stuart Pocock, Roxana Mehran

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Background: There is a paucity of data regarding the safety and efficacy of different antiplatelet regimens according to standardized body mass index (BMI) categories. Objectives: The aim of this study was to investigate bleeding and ischemic outcomes according to BMI in the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial. Methods: The TWILIGHT trial randomized high-risk patients to ticagrelor plus aspirin or ticagrelor plus placebo at 3 months after percutaneous coronary intervention. In this secondary analysis, patients were stratified by standard BMI categories, as recommended by the European Society of Cardiology Working Group on Thrombosis (normal weight [BMI 18.5-24.99 kg/m2], overweight [BMI 25-29.99 kg/m2], and obese [BMI ≥30 kg/m2]) and by median BMI, as prespecified in the protocol. Results: Among 7,038 patients randomized and with available BMI, 1,807 (25.7%) were normal weight, 2,927 (41.6%) were overweight, and 2,304 (32.7%) were obese. In normal-weight, overweight, and obese patients, ticagrelor monotherapy, compared with ticagrelor plus aspirin, reduced the primary endpoint of Bleeding Academic Research Consortium type 2, 3, or 5 bleeding (normal weight: HR: 0.48 [95% CI: 0.32-0.73]; overweight: HR: 0.57 [95% CI: 0.41-0.78]; obese: HR: 0.63 [95% CI: 0.44-0.91]; P for interaction = 0.627), without any increase in the composite ischemic endpoint of all-cause death, myocardial infarction, or stroke (normal weight: HR: 1.36 [95% CI: 0.84-2.19]; overweight: HR: 0.92 [95% CI: 0.63-1.35]; obese: HR: 0.84 [95% CI: 0.56-1.25]; P for interaction = 0.290). These findings were consistent with the prespecified analysis by median BMI. Conclusions: Among high-risk patients undergoing percutaneous coronary intervention, ticagrelor monotherapy, compared with ticagrelor plus aspirin, reduced bleeding events without any increase in ischemic risk across different BMI categories.

Original languageEnglish
Pages (from-to)1948-1960
Number of pages13
JournalJACC: Cardiovascular Interventions
Issue number19
StatePublished - Oct 10 2022

Bibliographical note

Publisher Copyright:
© 2022 American College of Cardiology Foundation


  • aspirin
  • body mass index
  • coronary artery disease
  • dual antiplatelet therapy
  • percutaneous coronary intervention
  • ticagrelor

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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