Bleeding and Ischemic Risks of Ticagrelor Monotherapy After Coronary Interventions

Guiomar Mendieta, Shamir Mehta, Usman Baber, Dominick J. Angiolillo, Carlo Briguori, David Cohen, Timothy Collier, George Dangas, Dariusz Dudek, Javier Escaned, Robert Gil, Birgit Vogel, Davide Cao, Alessandro Spirito, Kurt Huber, Adnan Kastrati, Upendra Kaul, Ran Kornowski, Mitchell W. Krucoff, Vijay KunadianDavid J. Moliterno, E. Magnus Ohman, Gennaro Sardella, Samantha Sartori, Samin Sharma, Richard Shlofmitz, P. Gabriel Steg, Ya Ling Han, Stuart Pocock, C. Michael Gibson, Roxana Mehran

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Background: In TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention), among high-risk patients undergoing percutaneous coronary intervention (PCI), ticagrelor monotherapy vs continuation of dual antiplatelet therapy (DAPT) with aspirin and ticagrelor after completing a 3-month course of DAPT was associated with reduced bleeding, without an increase in ischemic events. Objectives: This investigation sought to study the clinical benefit of ticagrelor monotherapy vs DAPT by simultaneously modeling its associated potential bleeding benefits and ischemic harms on an individual patient basis. Methods: Multivariable Cox regression models for: 1) Bleeding Academic Research Consortium type 2, 3, or 5 (BARC-2/3/5); and 2) cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke (major adverse cardiac and cerebrovascular event [MACCE]) were developed using stepwise forward variable selection. The coefficients in the BARC-2/3/5 and MACCE models were used to calculate bleeding and ischemic risk scores, respectively, for each patient (excluding the coefficient for randomized treatment). Results: In the total study group (N = 7,119), BARC-2/3/5 occurred in 391 (5.5%) patients, and MACCE occurred in 258 (3.6%). There was a consistent reduction in bleeding events associated with ticagrelor monotherapy compared with DAPT across both bleeding and ischemic risk strata (P interaction = 0.54 and 0.11, respectively). Importantly, this benefit associated with ticagrelor monotherapy was not offset by an increase in MACCE at any level of bleeding or ischemic risk. Conclusions: Three months after PCI, discontinuing aspirin and maintaining ticagrelor monotherapy reduces bleeding in both higher–bleeding risk and lower–bleeding risk patients compared with continued DAPT. This benefit does not appear to be offset by greater ischemic risk.

Original languageEnglish
Pages (from-to)687-700
Number of pages14
JournalJournal of the American College of Cardiology
Issue number8
StatePublished - Aug 22 2023

Bibliographical note

Publisher Copyright:
© 2023 American College of Cardiology Foundation


  • aspirin
  • dual antiplatelet therapy
  • monotherapy
  • ticagrelor

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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