JACC Cardiovasc Interv. 2025 Nov 24;18(22):2713-2724. doi: 10.1016/j.jcin.2025.09.026.
ABSTRACT
BACKGROUND: Diabetes mellitus (DM) is associated with suboptimal clopidogrel response and elevated thrombotic risk. The benefit of early de-escalation of dual antiplatelet therapy (DAPT) in DM patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) remains uncertain.
OBJECTIVES: The authors sought to assess whether a 1-month, unguided de-escalation from ticagrelor to clopidogrel is associated with clinical benefit compared with continued ticagrelor-based DAPT in MI patients with DM.
METHODS: This post hoc analysis included 859 patients with DM (31.9%) from the TALOS-AMI (Ticagrelor Versus Clopidogrel in Stabilized Patients With Acute Myocardial Infarction) trial who tolerated 1 month of ticagrelor-based DAPT post-PCI. Participants were randomized to continue ticagrelor or switch to clopidogrel for 11 months. The primary endpoint was a composite of ischemic (cardiovascular death, MI, and stroke), and bleeding (Bleeding Academic Research Consortium [BARC] type 2, 3, or 5 bleeding) endpoints.
RESULTS: De-escalation was consistently associated with a lower incidence of primary endpoint compared with continued ticagrelor (mainly driven by fewer BARC type 2 bleeding events), irrespective of diabetes status (Pinteraction = 0.467). In the DM cohort, differences in bleeding (HR: 0.48; 95% CI: 0.22-1.05; P = 0.066) and ischemic (HR: 0.57; 95% CI: 0.25-1.29; P = 0.176) endpoints were not significant. Results were consistent across subgroups stratified by glycemic control and PCI complexity. Significant treatment-by-DM interactions were observed for BARC type 3 or 5 bleeding (Pinteraction = 0.042) and target vessel revascularization (Pinteraction = 0.014).
CONCLUSIONS: In MI patients with DM, 1-month unguided de-escalation to clopidogrel after ticagrelor-based DAPT was associated with clinical benefit without increasing ischemic risk. These results warrant further prospective validation.
PMID:41297983 | DOI:10.1016/j.jcin.2025.09.026
