AIMS: PEGASUS-TIMI 54 demonstrated that long-term dual antiplatelet therapy (DAPT) with aspirin and ticagrelor reduced the risk of major adverse cardiovascular events (MACE), with an acceptable increase in bleeding, in patients with prior myocardial infarction (MI). While much of the discussion around prolonged DAPT has been focused on stented patients, patients with prior MI without prior coronary stenting comprise a clinically important subgroup. METHODS AND RESULTS: This was a pre-specified analysis from PEGASUS-TIMI 54, which randomized 21 162 patients with prior MI (1-3 years) and additional high-risk features to ticagrelor 60 mg, 90 mg, or placebo twice daily in addition to aspirin. A total of 4199 patients had no history of coronary stenting at baseline. The primary efficacy outcome (MACE) was the composite of cardiovascular death, MI, or stroke. Patients without history of coronary stenting had higher baseline risk of MACE [13.2% vs. 8.0%, adjusted hazard ratio (HR) 1.41, 95% confidence interval (CI) 1.15-1.73, in the placebo arm]. The relative risk reduction in MACE with ticagrelor (pooled doses) was similar in patients without (HR 0.82, 95% CI 0.68-0.99) and with prior stenting (HR 0.85, 95% CI 0.75-0.96; P for interaction = 0.76). CONCLUSION: Long-term ticagrelor reduces thrombotic events in patients with prior MI regardless of whether they had prior coronary stenting. These data highlight the benefits of DAPT in prevention of spontaneous atherothrombotic events and indicate that long-term ticagrelor may be considered in high-risk patients with prior MI even if they have not been treated with stenting. CLINICALTRIALS.GOV IDENTIFIER: NCT01225562.

Assistance Publique Hôpitaux de Paris 3 Avenue Victoria 75004 Paris France

AstraZeneca 431 53 Mölndal Sweden

Cardiovascular Division Faculty of Medicine Pontificia Universidad Católica de Chile Lira 40 Santiago Chile

Centre of Postgraduate Medical Education Grochowski Hospital Grenadierów 51 59 04 073 Warsaw Poland

College of Medicine University of the Philippines Philippine Heart Center East Quezon City Metro Manila Philippines

CPC Clinical Research University of Colorado School of Medicine 13199 E Montview Blvd Suite 200 Aurora CO USA

Department of Cardiology Military Hospital Róbert Károly krt 1134 Budapest Hungary

Department of Cardiology Stavanger University Hospital Gerd Ragna Bloch Thorsens gate 8 Stavanger Norway

Drammen Heart Center Dronninggata 28 3004 Drammen Norway

Instituto do Coracao Hospital das Clinicas da Faculdade de Medicina Universidade de Sao Paulo Av Dr Eneas de Carvalho Aguiar 44 05403 Sao Paulo Brazil

TIMI Study Group Cardiovascular Division Brigham and Women's Hospital Harvard Medical School Boston USA

University Hospital Brno 20 Jihlavska Brno Czech Republic

University Hospital of Parma Via Gramsci 14 43126 Parma PR Italy

University of Sheffield Western Bank Sheffield S10 2TN UK

Eur Heart J. 2020 May 1;41(17):1633-1635. doi: 10.1093/eurheartj/ehz912. PubMed

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Long-Term Ticagrelor in Patients With Prior Coronary Stenting in the PEGASUS-TIMI 54 Trial

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ClinicalTrials.gov
NCT01225562