Background Coronary
stent type and risk of
stent thrombosis remain important factors affecting recommended duration of dual antiplatelet
therapy. We investigated the efficacy and safety of long-term
ticagrelor in patients with prior coronary stenting enrolled in the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients with Prior
Heart Attack Using
Ticagrelor Compared to Placebo on a Background of
Aspirin-Thrombolysis in
Myocardial Infarction 54) trial. Methods and Results Patients in PEGASUS-TIMI 54 had a
myocardial infarction 1 to 3 year prior and were randomized 1:1:1 to
ticagrelor 60 or 90 mg BID or placebo. The primary end point was a composite of cardiovascular death,
myocardial infarction, or
stroke (major adverse cardiovascular events).
Stent thrombosis was prospectively adjudicated (Academic Research Consortium definition). Baseline characteristics were compared by most recent
stent type (bare
metal versus
drug-eluting stent and first- versus later-generation
drug-eluting stent). Treatment arms were compared using Cox proportional hazards models. Of 21 162 patients randomized, 80% (n=16 891) had prior coronary stenting. Following randomization,
myocardial infarction was the most frequent ischemic event in patients with prior stenting in the placebo arm, occurring in 5.2% of patients (Type 1: 4.1%), followed by cardiovascular death (2.3%),
stroke (1.7%), and
stent thrombosis (0.9%). Ticagrelorpooled reduced major adverse cardiovascular events (7.0% versus 8.0%; hazard ratio [HR], 0.85; 95% CI, 0.75-96) regardless of
stent type (bare
metal stent versus
drug-eluting stent: pinteraction=0.767; first versus later generation: pinteraction=0.940). The rate of any
stent thrombosis was numerically lower with ticagrelorpooled (0.7% versus 0.9%; HR, 0.73; 95% CI, 0.50-1.05) and Thrombolysis in
Myocardial Infarction major
bleeding was increased (HR, 2.65; 95% CI, 1.90-3.68). Conclusions Long-term
ticagrelor reduces major adverse cardiovascular events in patients with prior
myocardial infarction and coronary stenting regardless of
stent type, with the benefit driven predominantly by reduction in de novo events. Nonfatal major
bleeding is increased with
ticagrelor. Registration Information clinicaltrials.gov. Identifier: NCT01225562.