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1

Duration of DAPT after ACS

Robert Storey

Professor of Cardiology, University of Sheffield

and

Academic Director and Honorary Consultant Cardiologist,

Cardiology and Cardiothoracic Surgery Directorate,

Sheffield Teaching Hospitals NHS Foundation Trust,

Sheffield, United Kingdom

Disclosures

Company name Relationship

• AstraZeneca Research grant, honoraria, consultant

• Avacta Consultant

• Bayer Consultant

• BMS/Pfizer Consultant

• PlaqueTec Research grant, consultant

• Aspen Consultant

• ThermoFisher Scientific Consultant

• The Medicines Company Consultant

No. at risk

Clopidogrel

Ticagrelor

9291

9333

8560

8678

8405

8520

8177

Days after randomization

6703

6796

5136

5210

4109

4191

0 60 120 180 240 300 360

6

5

4

3

2

1

0

7

Cu

mu

lative

in

cid

en

ce

(%

)

Clopidogrel

Ticagrelor

5.8

6.9

8279

HR 0.84 (95% CI 0.75–0.95), p=0.005

0 60 120 180 240 300 360

6

4

3

2

1

0

Clopidogrel

Ticagrelor

4.0

5.1

HR 0.79 (95% CI 0.69–0.91), p=0.001

7

5

9291

9333

8865

8294

8780

8822

8589

Days after randomization

7079

7119

5441

5482

4364

44198626

Myocardial infarction Cardiovascular death

Cu

mu

lative

in

cid

en

ce

(%

)

PLATO Secondary efficacy endpoints

Wallentin L et al. N Eng J Med. 2009

PEGASUS-TIMI 54 study design

4

Stable patients >50 years old with history of MI 1–3 years prior + ≥1

additional atherothrombotic risk factor*

n ~21,000

Ticagrelor

60 mg BID

Placebo

BID

Ticagrelor

90 mg BID

Follow-up visits: 4-monthly for first year, then 6-monthly

Duration: Minimum 12 months, up to ~44 months (median 30 months)

Event-driven trial: n ~ 1360 events

Primary efficacy endpoint: CV death, MI or stroke

Primary safety endpoint: TIMI major bleeding

Randomized, double-blind

Planned treatment with ASA 75–150 mg

+ standard background care

*Age ≥65 years, diabetes, second prior MI, multivessel

CAD or chronic non-end-stage renal dysfunction

BID, twice daily; CAD, coronary artery disease; TIMI, thrombolysis in myocardial infarction

PEGASUS-TIMI 54: Primary endpoint

p<0.026 indicates statistical significance; CI, confidence interval; HR, hazard ratio

Bonaca MP et al. N Engl J Med. 2015;372:1791–1800.

No. at risk

Placebo

90 mg bid

60 mg bid

7067

7050

7045

6979

6973

6969

6892

6899

6905

6823

6827

6842

6761

6769

6784

6681

6719

6733

6508

6550

6557

6236

6272

6270

5876

5921

5904

5157

5243

5222

4343

4401

4424

3360

3368

3392

2028

2038

2055

Eve

nt

rate

(%

)

Months from randomization

Ticagrelor 60 mg vs placebo

HR 0.84 (95% CI 0.74–0.95) p=0.004

Ticagrelor 90 mg vs placebo

HR 0.85 (95% CI 0.75–0.96) p=0.008

Placebo

Ticagrelor 90 mg bid


9.04% Placebo

7.85% 90 mg bid

7.77% 60 mg bid

0 3 6 9 12 15 18 21 24 27 30 33 36

0

1

2

3

4

5

6

7

8

9

10

Rates are presented as 3-year Kaplan-Meier estimates

Bonaca MP et al. N Engl J Med 2015;372:1791–1800

0.6 0.70.6 0.6 0.6

0.5

0.10.3 0.3

P=NS P=NS P=NS

Fatal bleeding or

ICH

ICH Fatal bleeding

PEGASUS-TIMI 54: Bleeding3-y

ea

r K

M e

ve

nt ra

te

2.6

2.3

1.11.3

1.2

0.4

P<0.001

P<0.001

TIMI major

bleeding

TIMI minor

bleeding

5

4

3

2

1

0



Placebo

PEGASUS-TIMI 54 platelet function substudy

VerifyNow PRU

Storey RF et al. J Am Coll Cardiol. 2016

p=0.34

Placebo Ticagrelor

60 mg

Ticagrelor

90 mg

Placebo Ticagrelor

60 mg

Ticagrelor

90 mg

0

100

200

300

400

PR

U

Pre-dose Post-dose

PRU=208

p=0.73

Primary endpoint – landmark (ITT)

8

Median 1.7 y

(1.2–2.3)

Median 2.7 y

(2.2–3.3)

Median 4.7 y

(4.2–5.3)

Bonaca MP et al. Presented at AHA Congress 2015 (Abstract 383).

CV

D/M

I/s

tro

ke

(%

)

3.2%

2.8%

2.7%

5.9%

5.2%

5.1%

First year of treatment Subsequent 2 years of treatment

Ticagrelor 60 mg

HR 0.82

(95% CI 0.67–0.99)

p=0.037

Ticagrelor 90 mg

HR 0.86

(95% CI 0.71–1.03)

p=0.10

Ticagrelor 60 mg

HR 0.85

(95% CI 0.73–0.998)

p=0.047

Ticagrelor 90 mg

HR 0.85

(95% CI 0.72–0.99)

p=0.036

3.1%

2.8%

2.5%

0

1

2

3

4

5

6

7

0 90 180 270 360

0

1

2

3

4

5

6

7

366 456 546 636 726 816 906 996 1086

Placebo, N=6750

Ticagrelor 90 mg, N=6763


Placebo, N=7067



Time (days) from randomization

PEGASUS-TIMI 54: Efficacy

endpoints

*Indicates nominal p-value; p<0.026 indicates statistical significance.

Bonaca MP et al. N Engl J Med. 2015;372:1791–1800.

Ticagrelor better Placebo better

0.4 0.6 0.8 1 1.25 1.67

Primary – CV death, MI

or stroke (1558 events)

CV death

(566 events)

MI

(898 events)

Stroke

(313 events)

Endpoint3-year KM event

rates (%)

HR (95% CI) P-valueTicagrelor Placebo

7.85 9.04 0.85 (0.75–0.96) 0.008

7.77 9.04 0.84 (0.74–0.95) 0.004

7.81 9.04 0.84 (0.76–0.94) 0.001

2.94 3.39 0.87 (0.71–1.06) 0.15

2.86 3.39 0.83 (0.68–1.01) 0.07

2.90 3.39 0.85 (0.71–1.00) 0.06

4.40 5.25 0.81 (0.69–0.95) 0.01*

4.53 5.25 0.84 (0.72–0.98) 0.03*

4.47 5.25 0.83 (0.72–0.95) 0.005*

1.61 1.94 0.82 (0.63–1.07) 0.14*

1.47 1.94 0.75 (0.57–0.98) 0.03*

1.54 1.94 0.78 (0.62–0.98) 0.03*



Ticagrelor pooled

Effect of ticagrelor on CAD-related death

Death due to acute MI

Ticagrelor better Placebo better1.0

Ticagrelor vs placebo p-value

0.210.72 (0.43, 1.20)

HR (95% CI)

Ticagrelor doses pooled1.25 2.000.750.50

Sudden cardiac death 0.0190.77 (0.62, 0.96)

Coronary death 0.0480.78 (0.61, 0.9975)


Effect of ticagrelor on STEMI


0

0

0.5

1.0

1.5

2.0

Days from randomization

ST

EM

I (%

)

90 180 270 360 450 540 630 720 810 900 990 1080

Placebo

Ticagrelor 60 mg

Ticagrelor 90 mg

Ticagrelor 60 mg

HR 0.62

(95% CI 0.45, 0.86)

p=0.0016

Ticagrelor 90 mg

HR 0.57

(95% CI 0.41, 0.79)

p=0.0008

Effect of ticagrelor 60mg on stroke

Bonaca MP et al. Circulation 2016

Adverse eventTicagrelor 90 mg bid

N=7050; n (%)


N=7045; n (%)

Placebo

N=7067; n (%)

All-cause death 336 (4.8) 299 (4.2) 336 (4.8)

Non-CV death 145 (2.1) 117 (1.7) 115 (1.6)

Accident/trauma 6 (0.09) 2 (0.03) 4 (0.06)

Infection/sepsis 31 (0.44) 25 (0.36) 24 (0.34)

Malignancy 77 (1.10) 64 (0.92) 53 (0.76)

Pulmonary failure 10 (0.14) 9 (0.13) 9 (0.13)

Renal failure 2 (0.03) 4 (0.06) 4 (0.06)

Other 19 (0.27) 13 (0.19) 21 (0.30)

PEGASUS-TIMI 54: Non-CV deaths

Includes deaths occurring after the common study end date (safety window).

Data presented as proportions.

n=number of patients with events, not the number of events.

Bonaca MP et al. N Engl J Med. 2015, Supplementary Appendix [Epub ahead of print].

PEGASUS TIMI 54: MACE in patients randomized to

placebo by time from P2Y12 inhibitor withdrawal

0%

2%

4%

6%

8%

10%

12%

0 90 180 270 360 450 540 630 720 810 900 990 1080

0,0%

0,5%

1,0%

1,5%

2,0%

0 30 60 90

CV

D/M

I/str

oke (

%)


1.46%

0.60%0.55%

9.9%

8.7%

6.9%

≤30 days

30 days–≤1 Year>1 Year

Adj. HR 1.47

(95% CI

1.12–1.93)

Adj. HR 1.28

(95% CI

0.98–1.67)

Ref.

p-trend 0.0097

Adjusted for baseline characteristics that differed between

groups including age, sex, race, region, time from qualifying

MI, diabetes, multivessel disease, hypertension,

hypercholesterolemia and history of PCI/stent.

Bonaca M et al. Eur Heart J. 2015 online.

Reduction in CV death, MI or stroke with ticagrelor

by time from P2Y12 inhibitor withdrawal

Ticagrelor 90 mg

Ticagrelor 60 mg

PooledPlacebo betterTicagrelor better

0.70 (0.57, 0.87)

0.75 (0.61, 0.92)

0.73 (0.61, 0.87) <0.001

0.90 (0.72, 1.12)

0.82 (0.65, 1.02)

0.86 (0.71, 1.04) 0.11

0.96 (0.73, 1.26)

1.06 (0.81, 1.38)

1.01 (0.80, 1.27) 0.96

1.0

HR (95% CI) p-value

≤30 days

n=7181

>30 days

to 1 year

n=6501

>1 year

n=5079

Time from P2Y12 inhibitor

withdrawal to randomization

Bonaca MP. Presented at ESC Congress 2015 (Abstract 3918).

p-interaction 0.0097

27% RRR

14% RRR

RRR

0.7 0.9 1.1

Efficacy of ticagrelor by eGFR

0

2

4

6

8

10

0 12 24 36

Months since randomization

3-y

ear

Kap

lan

-Meie

r %

13.99%

11.29%

7.43%

6.80%

HR (95% CI)

0.81 (0.68, 0.96)

ARR=2.70%

12

14

16

eGFR ≥60 ticagrelor pooled (n=10 713)

eGFR <60 placebo (n=1649)

eGFR <60 ticagrelor pooled (n=3200)

HR (95% CI)

0.88 (0.77, 1.00)

ARR=0.63%

eGFR ≥60 placebo (n=5336)

Primary endpoint: CV death, MI, stroke

ARR, absolute risk reduction.

Magnani G. Presented at ESC Congress 2015 (Abstract P3032).


Benefit in diabetic vs non-diabetic patients:

Interaction p=0.21

3.4%

2.3%

1.5%

1.4%

Ticagrelor in non-diabetic patients

HR 0.88 (95% CI 0.65–1.19)

ARR 0.1%; p=0.39

Ticagrelor in diabetic patients

HR 0.66 (95% CI 0.48–0.91)

ARR 1.1%; p=0.01

Ticagrelor (doses pooled)

Placebo

Bhatt DL et al. J Am Coll Cardiol. 2016.

PEGASUS-TIMI 54 diabetes substudy:

CAD-related death

Co

ron

ary

death

PEGASUS-TIMI 54: Estimates of first efficacy

and bleeding events prevented and caused

Rates are annualised from 3-year Kaplan-Meier event rates in the intention-to-treat population.

Bonaca MP et al. N Engl J Med. 2015, Supplementary Appendix [Epub ahead of print].



CV death, MI or stroke

TIMI major bleeding

Nu

mb

er

of

eve

nts

pe

r 1

0 0

00

pa

tie

nts

init

iate

d o

n t

rea

tme

nt

for

1 y

ea

r

–40–42

41

31

Total events: efficacy and safety

20

Murphy SA et al. Presented at AHA Congress 2015 (Abstract 742).

p-value 0.006 0.07 0.07 0.11 <0.001 0.99

0

Events from ITT population

and predicted incidence rates

p-values based on negative

binomial regression

0

Adverse events leading to

discontinuation

86

35451

297

96

103

388

385

0

200

400

600

800

1000

1200

Placebo Ticagrelor 60 mg BID

Other

Arrhythmia

Dyspnoea

Bleeding

Nu

mb

er

of p

atie

nts

p=NS each for D/C for

arrhythmia or other

AE, adverse event; D/C, discontinuation; NS, not significant.

Bonaca MP et al. Presented at AHA Congress 2015 (Late Breaking Clinical Trial).

Treatment arm Any AE Bleeding Dyspnoea

Ticagrelor 60 mg bid 16.4% 6.2% 4.6%

Placebo 8.9% 1.5% 0.8%

3 year KM rate (%) – p-value for 60 mg ticagrelor versus placebo <0.001

Drug discontinuation for AE by treatment arm


Ka

pla

n-M

eie

r ra

te (

%)

First year Years 2 + 3

18

16

14

12

10

8

6

4

2

0

0 90 180 270 360

6.0%

4.5%

18

16

14

12

10

8

6

4

2

0

366 456 546 636 816 1086996906726

13%

6%

22Bonaca MP et al. Presented at AHA Congress 2015 (Late Breaking Clinical Trial)

P value for each

dose vs placebo

< 0.01

P<0.01 for each dose

vs placebo

DAPT study: Continuation or withdrawal of

thienopyridine 12 months after coronary stenting

Mauri et al. NEJM 2014

~ 26% with MI

Death, MI or stroke

Withdrawal of

P2Y12

Inhibition

Withdrawal of

P2Y12

Inhibition

Individual CV Endpoints

6,4

2,3

3,5

1,4

0,6

7,5

2,6

4,4

1,71,4

0

1

2

3

4

5

6

7

8

9

10

MACE CV Death MI Stroke Stent Thrombosis (Def/Prob)

Eve

nt

Ra

te (

%)

Extended DAPT

Aspirin Alone

RR 0.78

P = 0.001

RR 0.85

P = 0.03

RR 0.70

P = 0.003

RR 0.81

P = 0.02RR 0.50

P = 0.02

Udell JA, et al. Eur Heart J 2015 at eurheartj.oxfordjournals.org.

Long-term DAPT post MI: meta-analysis (n=33,435)

1,9

0,4 0,1

1,7

4,0

1,1

0,3 0,2

1,6

4,2

0

1

2

3

4

5

6

7

8

9

10

Major Bleeding

ICH Fatal Bleeding

Non-CV Death

All-Cause Death

Eve

nt

Ra

te (

%)

Extended DAPT

Aspirin Alone

RR 1.73

P = 0.004

P = NS

RR 1.03

P = NS

RR 0.92

P = NS

Major Bleeding Events and Safety

P = NS

Udell JA, et al. Eur Heart J 2015 at eurheartj.oxfordjournals.org.

Long-term DAPT post MI: meta-analysis (n=33,435)

Conclusions

• Extended DAPT post-MI reduces risks of stent thrombosis

and ischaemic events at the expense of increased risk of non-

fatal major bleeding

• The higher the ischaemic risk, the greater the absolute risk

reduction with extended DAPT post MI e.g. CKD, DM, PAD

• Extended ticagrelor-based DAPT associated with numerically

lower rates of all-cause death in the 60 mg bid group due to

lower rates of CV death, particularly CAD-related death, and

no excess of non-CV death

• Extended thienopyridine-based DAPT may be an alternative

to ticagrelor-based DAPT but relative efficacy and safety of

the regimens is uncertain

• Efficacy data for aspirin/NOAC combination awaited with

interest

My personal opinion

• Long-term ticagrelor 60 mg bid and aspirin 75 mg od is

recommended in post-MI patients at high risk of CAD-

related death who do not have high risk of fatal bleeding

• Long-term thienopyridine-based DAPT may be

considered in ticagrelor-intolerant patients at high risk of

CAD-related death

• Coronary anatomy should be considered along with

clinical variables when deciding on duration of DAPT

post-MI in order to guide risk of CAD-related death

• Duration of DAPT can be recommended following the

coronary angiography procedure but reviewed at any

stage should complications arise

Example of discharge letter

advice….

Follow-up by GP: Please continue ticagrelor 90 mg bd for 1 year

and then downtitrate to 60 mg bd long term, if tolerated, in view

of extent of coronary artery disease and clinical risk factors.

Continue aspirin, statin and other secondary prevention

medication long term.

x

ThromboxaneA

2

5HT

P2Y12

ADP ADPADP

5HT

P2Y15HT2A

PAR-1

PAR-4

Dense

granule

Thrombin

generation

Shape

change

aIIbb3

aIIbb3

FibrinogenaIIbb3

Aggregation

AmplificationAlpha

granule

Coagulation factors

Inflammatory mediators

TPa

Coagulation

GPVI

Collagen

ATPATP

P2X1

ASPIRIN

x TICLOPIDINE

CLOPIDOGREL

PRASUGREL

ACTIVE

METABOLITE

x TICAGRELOR

CANGRELOR

GP IIb/IIIa ANTAGONISTS

xx

VORAPAXAR

x

HEPARINS

FONDAPARINUX

BIVALIRUDIN

RIVAROXABAN

APIXABAN

DABIGATRANThrombin

?

Discussion

ADP, adenosine diphosphate; ATP, adenosine triphosphate; GP = glycoprotein; PAR = protease-activated receptor; TP, thromboxane A2/prostaglandin H2.Storey RF. Curr Pharm Des. 2006.

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