Ticagrelor monotherapy reduced bleeding events without increasing the risk of ischemic events compared to ticagrelor plus aspirin across different body mass index (BMI) categories, according to new study results. Vijay Kunadian, MBBS, MD, from Newcastle University and Freeman Hospital, Newcastle upon Tyne, England, and colleagues reported these findings from a post hoc analysis of the TWILIGHT trial published Monday online and in the Oct. 10 issue of JACC: Cardiovascular Interventions. The TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial randomized high-bleeding-risk patients at 3 months after percutaneous coronary intervention (PCI) to either ticagrelor alone or ticagrelor plus aspirin. The authors stratified the study population according to different BMI categories as recommended by European Society of Cardiology (ESC) Working Group on Thrombosis as: normal weight (BMI 18.5-24.99 kg/m2), overweight (BMI 25-29.99 kg/m2) and obese (BMI ≥30 kg/m2). Patients with BMI <18.5 kg/m2 were excluded due to very small sample size (n=52). The final study cohort included 7,038 patients: 1,807 (25.7%) normal weight, 2,927 (41.6%) overweight and 2,304 (32.7%) obese. Baseline clinical and procedural characteristics were comparable across different BMI categories, except patients with higher BMI tended to be younger and had a higher burden of cardiovascular risk factors, including hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, hypertension and prior PCI. Normal-weight patients were more frequently enrolled in Asia, obese patients in North America and overweight in Europe. The use of radial artery access was lower among obese patients. The study demonstrated that ticagrelor monotherapy, compared with ticagrelor plus aspirin, reduced the primary endpoint of Bleeding Academic Research Consortium type 2, 3 or 5 bleeding across all BMI categories, (normal weight: hazard ratio [HR] 0.48 [95% confidence interval (CI): 0.32-0.73]; overweight: HR 0.57 [95% CI: 0.41-0.78]; obese: HR 0.63 [95% CI: 0.44-0.91]; p for interaction = 0.627), without any increase in the composite ischemic endpoint of all-cause death, myocardial infarction or stroke (normal weight: HR 1.36 [95% CI: 0.84-2.19]; overweight: HR 0.92 [95% CI: 0.63-1.35]; obese: HR 0.84 [95% CI: 0.56-1.25]; p for interaction = 0.290). The key limitation of this study is that it is a post hoc analysis and should be interpreted as hypothesis-generating. Further, the study is likely underpowered to detect significant differences, especially for ischemic events, given subgroup analyses. Also, the results cannot be extrapolated to underweight patients, as they were excluded, the authors noted. In an accompanying editorial, Joaquin E. Cigarroa, MD, of Oregon Health and Sciences University, and H.V. “Skip” Anderson, MD, of the University of Texas Health Science Center Houston, stated that the current evidence suggests that ticagrelor may in fact be the best choice for obese patients treated with PCI. However, they wrote, more data are needed to study the affect of plasma concentrations of both ticagrelor and its active metabolite across various BMI categories, to better understand the efficacy and safety profiles of these drugs. Sources: Kunadian V, Baber U, Pivato CA, et al. Bleeding and Ischemic Outcomes With Ticagrelor Monotherapy According to Body Mass Index. JACC Cardiovasc Interv. 2022;15:1948–1960. Cigarroa JE, Anderson HVS. Antithrombotic Therapies and Body Mass Index: Does One Size Fit All? JACC Cardiovasc Interv. 2022;15:1961–1964. Image Credit: luchschenF – stock.adobe.com