Long-term ticagrelor with aspirin reduces thrombotic events in patients with prior MI and no stenting

  • Furtado RHM & al.
  • Eur Heart J
  • 7 Dec 2019

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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  • Long-term dual antiplatelet therapy (DAPT) with ticagrelor and aspirin decreased atherothrombotic risk in patients with prior myocardial infarction (MI) irrespective of previous coronary stenting.
  • Risk reduction was higher in patients without stenting compared to those with stenting.

Why this matters

  • Findings highlight the benefits of DAPT in the prevention of spontaneous atherothrombotic events and suggest that ticagrelor may be considered for long-term in high-risk patients with prior MI and no history of stenting.

Study design

  • The PEGASUS-TIMI 54 study of 21,090 patients with prior MI (1-3 years; 4199 without stenting and 16,891 with ≥1 stents) who were randomly assigned to receive ticagrelor (60 and 90 mg) or placebo twice daily in addition to aspirin.
  • Primary outcomes: major adverse cardiovascular events (MACEs; cardiovascular (CV) death, MI and stroke).
  • Exploratory net clinical outcome: composite of CV death, MI, stroke, fatal bleeding or intracranial haemorrhage.
  • Funding: AstraZeneca to Brigham and Women’s Hospital.

Key results

  • Within the placebo group, patients without stenting had a higher absolute risk for MACEs vs those with stenting (HR, 1.41; 95% CI, 1.15-1.73; P=.0008).
  • Risk reduction in MACE with ticagrelor was similar in patients without (HR, 0.82; 95% CI, 0.68-0.99) and with (HR, 0.85; 95% CI, 0.75-0.96; Pinteraction=.76) stenting.
  • Ticagrelor vs placebo group had a lower risk for CV death (HR, 0.80; 95% CI, 0.62-1.03; P=.087) and all-cause mortality (HR, 0.79; 95% CI, 0.64-0.99; P=.036) in patients without stenting.
  • The risk for major bleeding increased with ticagrelor in patients without (HR, 1.93; 95% CI, 0.99-3.78) and with (HR, 2.65; 95% CI, 1.90-3.68; Pinteraction=.41) stenting.


  • Subgroup analysis was not powered for all MACE components and safety endpoints.