Ticagrelor vs Aspirin in Patients undergoing Coronary- Artery … · 2018-11-12 · Ticagrelor vs...

Ticagrelor vs Aspirin in Patients undergoing Coronary-Artery Bypass Grafting

Heribert Schunkert, MDon behalf of

the TiCAB Investigators

The TiCAB Trial

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• Steering CommitteeProf. Dr. H. Schunkert, Prof. Dr. A. Böning, Prof. Dr. J. Cremer, Prof. Dr. C. Hamm, Prof. Dr. A. Kastrati, Prof. Dr. R. Lange, Prof. Dr. K. Laugwitz,

Prof. Dr. S. Massberg, Prof. Dr. P. Radke, Ass.-Prof. Dr. S. Sandner, Prof. Dr. R. Schulz, Prof. Dr. H.-H. Sievers, Prof. Dr. U. Zeymer

• Principal InvestigatorsProf. Dr. H. Schunkert, Prof. Dr. S. Sandner, Prof. Dr. A. Böning, Prof. Dr. R. Hambrecht, PD Dr. T. Attmann, Dr. M. Oberhoffer, PD Dr. C. Knosalla, Prof. Dr. T. Walther, PD Dr. B. Danner, Prof. Dr. M. Misfeld, Prof. Dr. G. Wimmer-Greinecker, Prof. Dr. U. Zeymer, Prof. Dr. M. Siepe, PD Dr. H. Grubitzsch, Dr. A. Joost, Dr. L. Conradi, Prof. Dr. I. Friedrich, Prof. Dr. L.

Englberger, Prof. Dr. J. M. Albes, Prof. Dr. T. Fischlein, PD Dr. A. J. Rastan, Prof. Dr. M. Kelm, Prof. Dr. R. Autschbach, Dr. T. Sandhaus,

Dr. J. Krülls-Münch, Prof. Dr. J. vom Dahl

• Data Safety Monitoring BoardProf. Dr. M. Gottwik (Chair), Prof. Dr. H. Oelert, Prof. Dr. S. Hagl,

Prof. Dr. T. Meinertz, Prof. Dr. K. Wegscheider

• Event Adjudication CommitteeProf. Dr. U. Tebbe (Chair), Prof. Dr. B. Nowak, Dr. J. Stritzke

TiCAB Investigators

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• Graft failure peaks in first year and is related to major adverse events

• Graft failure and other ischemic events may be prevented by more intensive platelet inhibition – but

• this needs to be balanced for bleeding risks

TiCAB: Background

After CABG Surgery

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Ticagrelor, as compared to aspirin,

reduces major adverse cardiovascular events

within one year after CABG operation.

Study Hypothesis

Aspirin vs Ticagrelor after CABG - TiCAB Trial

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•Randomized•Double blind•Parallel group •International multicenter•Phase III study•with one planned interim analysis by the DSMB.

Study Design Stratification

ACS patients

Stable anginapatientsRandomisation

Aspirin Group

TicagrelorGroup

1:1

90mg twice daily or 100mg once daily for 12 months

An investigator initiated trial partially funded through a grant by AstraZeneca

Aspirin vs Ticagrelor after CABG - TiCAB Trial

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• Incidence of:−Cardiovascular death −Myocardial infarction −Stroke−Recurrent revascularization

Primary Endpoint @ 12 months*

Aspirin vs Ticagrelor after CABG - TiCAB Trial

* Supported by a power calculation and incidence rates observed in STICH, SYNTAX and PLATO-CABG

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• Incidence of major bleeding events

Safety Endpoint @ 12 months*

Aspirin vs Ticagrelor after CABG - TiCAB Trial

* Periprocedural CABG and hospital stay-related: BARC 4 & 5Post-discharge: BARC ≥Type 3

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1. Patients 18 years of age or older – and 2. Informed, written consent by the patient – and 3. Indication for CABG surgery – and

- coronary three vessel disease, or- left main stenosis, or - two vessel disease with impaired EF (< 50%)

Inclusion Criteria

Aspirin vs Ticagrelor after CABG - TiCAB Trial

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1. Cardiogenic shock, haemodynamic instability2. Indication for oral anticoagulation or dual antiplatelet therapy 3. Concomitant non-coronary surgery (e.g. valve replacement)4. Contraindication for Aspirin or Ticagrelor use (e.g. known allergy)5. ...

Exclusion Criteria

Aspirin vs Ticagrelor after CABG - TiCAB Trial

Recruitment (cumulative)04/2013 – 03/2017

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September 2016cancelation of funding by

the manufacturer of ticagrelor

TiCAB Trial - Recruitment

3760 patients plannedby power calculation

Total recruitment:1893 patients

March 2018DSMB suggested

to stop the trial

Baseline Characteristics (I)Aspirin vs Ticagrelor after CABG - TiCAB Trial

Aspirin vs Ticagrelor after CABG - TiCAB Trial

Baseline Characteristics (II)

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Results – CV death, MI, stroke, repeat revascularization

Months after Enrollment

Prim

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Primary End PointAspirinTicagrelor HR 1.19

95% CI 0.87-1.62 P=0.27

8.2%

9.7%

Aspirin vs Ticagrelor after CABG - TiCAB Trial

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Results – Secondary Endpoints

Months after Enrollment

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Myocardial infarctionAspirinTicagrelor

Months after Enrollment

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Cardiovascular DeathAspirinTicagrelor

1.4%

1.2%

HR 0.85 CI 0.38-1.89 P=0.68

3.4%

2.1%

HR 0.63 CI 0.36-1.12 P=0.12

Aspirin vs Ticagrelor after CABG - TiCAB Trial

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Results – Secondary Endpoints

Months after Enrollment

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Revascularization

AspirinTicagrelor

Months after Enrollment

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StrokeAspirinTicagrelor

HR 1.21 CI 0.70-2.08 P=0.49

5.0%

3.9%

3.2%

2.6%

HR 1.28CI 0.82-2.00P=0.28

Aspirin vs Ticagrelor after CABG - TiCAB Trial

Results – MACE and Total mortality

Months after Enrollment

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MACEAspirinTicagrelor

Months after Enrollment

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All Cause DeathAspirinTicagrelor

2.5%

2.4%

6.5%

6.3%

HR 0.99 CI 0.69-1.42P=0.94

HR 0.96CI 0.53-1.72P=0.89

*CV death, myocardial infarction or stroke

*

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Results – Bleeding events

Months after Enrollment

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Bleeding (BARC 3, 4 and 5)AspirinTicagrelor

3.7%

3.2%

HR 1.17 CI 0.71-1.92P=0.53

Aspirin vs Ticagrelor after CABG - TiCAB Trial

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Results –Primary Endpoint

Subgroup analysis

Aspirin vs Ticagrelor after CABG - TiCAB Trial

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• The event rates were lower than expected

• The study was terminated early after half of the anticipated

patients were included

• A main source of funding terminated the contract

• The DSMB suggested to stop recruitment

• Ticagrelor displayed no signal for better outcome

Limitations of the Study

Aspirin vs Ticagrelor after CABG - TiCAB Trial

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The use of ticagrelor monotherapy instead of aspirin

monotherapy in patients undergoing CABG did not

significantly impact the rates of major CV events

nor major bleeding events.

Conclusion of the Study

Aspirin vs Ticagrelor after CABG - TiCAB Trial

Thank you for your attention!

Aspirin vs Ticagrelor after CABG - TiCAB Trial

THANK YOU!

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SYNTAX trial (3VD and LM):MACCE rate 12.4% at 1 year

STICH trial (CHF):Mortality 12% at 1 year

PLATO-CABG (ACS): MACCE Ticagrelor/ Aspirin 10.6%Clopidogrel/ Aspirin: 13.1%

TiCAB (3VG, LM, 2VD+EF<50% - stable CAD and ACS) Primary end point: CV death, MI, stroke and revascularisation• estimated event rate: 13% in the control group• Two-sided α level of 0.0492 (0.05 adjusted for a planned interim analysis)• Power of 0.80• Expected relative risk of 0.775 in the active group • Total of 3760 patients required

N Engl J Med 2009

N Engl J Med 2009

JACC 2011

TiCAB: Power calculation

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Trial Enrollment, Randomization and Follow-up

Aspirin vs Ticagrelor after CABG - TiCAB Trial

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Follow-up

Aspirin vs Ticagrelor after CABG - TiCAB Trial

• The trial was continued with in-house funding of the German Heart Center

• The planned interim analysis by the DSMB was scheduled for March 2018

• The DSMB suggested the trial to be stopped

Deutsches Herzzentrum MünchenLazarettstr. 3680636 Munich, Germany

Facilitated through a grant by AstraZeneca GmbH

A Randomized, Parallel Group, Double-Blind Study of Ticagrelor Compared with Aspirin for Prevention of Vascular Events in Patients Undergoing

Coronary Artery Bypass Graft Operation*April 2013 to May 2018

* de Waha et al Am Heart J. 2016;179:69-76

Sponsor

TiCAB – an investigator initiated trial

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•1st Visit: CABG - Hospital visit

•2nd Visit: 3 months after CABG - Hospital visit

•3rd Visit: 6 months after CABG - Telephone visit

•4th Visit: 9 months after CABG - Telephone visit

•5th Visit: 12 months after CABG - Hospital visit

Follow-up

Aspirin vs Ticagrelor after CABG - TiCAB Trial