Factors Related to Major Bleeding After Ticagrelor Therapy: Results from the TICO Trial

Jae Young Cho, Seung-Yul Lee, Kyeong Ho Yun, Byeong-Keuk Kim, Sung-Jin Hong, Jum Suk Ko, Sang Jae Rhee, Seok Kyu Oh, Dong-Ho Shin, Chul-Min Ahn, Jung-Sun Kim, Young-Guk Ko, Donghoon Choi, Myeong-Ki Hong, Yangsoo Jang, Jae Young Cho, Seung-Yul Lee, Kyeong Ho Yun, Byeong-Keuk Kim, Sung-Jin Hong, Jum Suk Ko, Sang Jae Rhee, Seok Kyu Oh, Dong-Ho Shin, Chul-Min Ahn, Jung-Sun Kim, Young-Guk Ko, Donghoon Choi, Myeong-Ki Hong, Yangsoo Jang

Abstract

Background There is a lack of data on factors that are related to clinically relevant bleeding after ticagrelor treatment. We investigated the clinical and procedural factors related to major bleeding in patients with acute coronary syndrome treated with ticagrelor after coronary stent implantation. Methods and Results From the TICO (Ticagrelor Monotherapy After 3 Months in Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome) randomized trial, a total of 2660 patients were included for the present study. Patients with major bleeding, defined by TIMI (Thrombolysis in Myocardial Infarction) major or Bleeding Academic Research Consortium type 3 or 5, were compared with those without major bleeding. On the basis of multivariable and receiver operating characteristic curve analyses, weight ≤65 kg, hemoglobin ≤12 g/dL, and estimated glomerular filtration rate <60 mL/min per 1.73 m2 were associated with an increased risk of major bleeding. In contrast, 3-month aspirin therapy with continued ticagrelor (versus 12-month aspirin and ticagrelor) was associated with a decreased risk of major bleeding. The lower risk of a net adverse clinical event (a composite of TIMI major bleeding and major adverse cardiac and cerebrovascular events) in patients treated with 3-month aspirin therapy reported from the TICO trial remained valid in patients with any of these risk factors (hazard ratio, 0.59; 95% CI, 0.39-0.90; Pinteraction=0.74). Conclusions Low body weight, anemia, and chronic kidney disease were risk factors for major bleeding after ticagrelor therapy. Early aspirin discontinuation had a net clinical benefit among patients with a bleeding risk. Registration URL: https://www.clinicaltrials.gov/. Unique Identifier: NCT02494895.

Keywords: acute coronary syndrome; antiplatelet therapy; drug‐eluting stent.

Conflict of interest statement

None.

Figures

Figure 1. Distribution of major bleeding events.
Figure 1. Distribution of major bleeding events.
A, TIMI (Thrombolysis in Myocardial Infarction) major bleeding. B, Bleeding Academic Research Consortium type 3 or 5 bleeding.
Figure 2. Event rates for major bleeding,…
Figure 2. Event rates for major bleeding, at 12‐month follow‐up.
A, TIMI (Thrombolysis in Myocardial Infarction) major bleeding. B, Bleeding Academic Research Consortium type 3 or 5 bleeding. HR indicates hazard ratio.
Figure 3. Time‐to‐event curves for net adverse…
Figure 3. Time‐to‐event curves for net adverse clinical event in patients with risk of major bleeding.
Hazard ratio (95% CI) was noted. A, Early aspirin discontinuation. B, Transradial intervention.

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