Abstract 14161: Long-Term Secondary Prevention With Ticagrelor for Prior Myocardial Infarction in Patients With No Coronary Stenting: A Sub-Analysis From PEGASUS TIMI 54.

Introduction: Prolonged dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor was initially developed to reduce risk of stent thrombosis. However, data has emerged showing that, in patients with MI, prolonged DAPT is beneficial, irrespective of stenting. Moreover, previous reports have suggested that MI patients not treated with coronary stenting may be at higher long-term risk. Hypothesis: Patients with a history of MI without coronary stenting, when compared with MI patients with a history of stenting, are at higher risk of adverse cardiovascular events and derive similar relative and greater absolute risk reduction with prolonged DAPT. Methods: PEGASUS-TIMI 54 randomized 21,162 patients with prior MI (1-3 years) to ticagrelor 60 mg, 90 mg or placebo twice daily. Primary efficacy outcome was MACE composite of: cardiovascular (CV) death, MI or stroke. History of coronary stenting or not was prespecified as subgroups of interest. Risk of MACE and benefit of ticagrelor (pooled doses) in patients with and without a history of stenting are compared. Results: 4,199 individuals had no history of coronary stenting at baseline whereas 16,891 did. The relative risk reduction (RRR) in MACE with ticagrelor was consistent in patients without (18% RRR) and with prior stenting (15% RRR) (Pint = 0.95, Figure). Given the higher baseline risk, patients without a history of stenting had a higher absolute risk reduction (2.1% vs. 1.0%). Furthermore, ticagrelor reduced all-cause mortality in these high-risk patients. (Figure) Conclusions: Prolonged DAPT with ticagrelor was equally beneficial in reducing relative risk of MACE in patients with and without prior stenting. In the latter group, absolute risk reduction was even higher due to their baseline risk profile. These data indicate that the benefits of long-term DAPT are driven primarily through reduction of de-novo atherothrombosis rather than stent protection. [ABSTRACT FROM AUTHOR]