Abbreviated Ticagrelor Based Dual Antiplatelet Therapy in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

Background Few randomized clinical trials have evaluated the safety and efficacy of abbreviated ticagrelor based dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS); however, these trials were underpowered to detect differences in hard clinical outcomes. Methods A systematic search of MEDLINE, Cochrane, and Scopus databases was performed through June 2024, for trials that compared abbreviated (≤3-months) versus standard 12-months ticagrelor based DAPT in ACS. The primary endpoint was all-cause mortality. Secondary endpoints included cardiovascular death, myocardial infarction, stent thrombosis, ischemic stroke, and major bleeding. Endpoints were measured at 12-months after DAPT initiation. Data were pooled using random-effects model. Effect measure utilized was risk ratio (RR). Heterogeneity was assessed via Chi-squared and Higgin's I2 test. RevMan 5.0 (Cochrane Collaboration, Oxford, United Kingdom) was utilized to perform statistical analysis. Results Five trials were included in this analysis with 21,407 patients assessed. ULTIMATE-DAPT, T-PASS, and GLOBAL LEADERS-ACS assessed 1-month DAPT duration while TICO and TWILIGHT-ACS assessed 3-months DAPT duration. The average age was 62.7 years and 22.7 % were women. ACS presentations included non-ST elevation myocardial infarction (40.1 %), unstable angina (35.2 %), and ST-segment elevation myocardial infarction (31.5 %). Abbreviated ticagrelor based DAPT was associated with lower risk of all-cause mortality (RR 0.78; 95 % Confidence Interval (CI) 0.62–0.98, I2 = 0 %) compared with standard duration DAPT. There was no difference between groups in cardiovascular death (RR 0.65; 95 % CI 0.41–1.03, I2 = 0 %), myocardial infarction (RR 1.04; 95 % CI 0.85–1.27, I2 = 0 %), stent thrombosis (RR 0.97; 95 % CI 0.64–1.45, I2 = 0 %), or ischemic stroke (RR 0.90; 95 % CI 0.62–1.30, I2 = 0 %). Abbreviated DAPT was associated with lower risk of major bleeding (RR 0.50; 95 % CI 0.38–0.66, I2 = 46 %). Conclusion Our analysis includes the totality of randomized data evaluating the merits of abbreviated ticagrelor based DAPT after ACS. The salient study finding was the observed reduced risk of all-cause mortality and major bleeding with abbreviated DAPT approach.