Prolonged dual antiplatelet therapy with ticagrelor 60 mg twice daily in patients with a prior myocardial infarction: real-world insights on incidence and reasons for non-compliance

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BACKGROUND: Prolonged dual antiplatelet therapy (DAPT) with ticagrelor 60 mg is recommended in post-myocardial infarction (MI) patients at moderate to high ischemic risk. Beyond physician-led discontinuation, persistence with therapy in real-world settings may be limited due to adverse effects and patient choices. The aim of this study is to assess the real-world incidence of non-compliance with prolonged DAPT and to elucidate reasons for discontinuation. METHODS: A retrospective observational study was conducted in three high-volume Italian PCI centers, involving patients with prior MI (1-3 years before) prescribed with ticagrelor 60 mg twice daily. Demographic, clinical, and procedural data were collected, with follow-up to determine therapy discontinuation and reasons for it. RESULTS: Among 244 enrolled patients, mean age was 66 years, and 83.6% were male. During follow-up (mean duration: 27.6 months), 10.2% (95% CI: 6.7% to 14.8%) discontinued ticagrelor. Key reasons included voluntary decision (40.0% [21.1% to 61.3%]) and bleeding events (40.0% [21.1% to 61.3%]), with some switching to high-dose regimens post-revascularization. In univariate analysis, ticagrelor discontinuation was significantly associated with female sex, higher BMI, prior PCI or CABG, high bleeding risk, and the absence of multivessel disease or primary PCI. However, in multivariable analysis, only multivessel disease remained independently associated with a lower likelihood of discontinuation (P<0.001). CONCLUSIONS: Real-world persistence with prolonged DAPT remains a challenge, often hindered by patient-driven discontinuation and adverse events. Enhanced patient education on therapy benefits and adherence may improve long-term outcomes.

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