For patients with chronic kidney disease (CKD) who underwent percutaneous coronary intervention (PCI), ticagrelor monotherapy was more effective at reducing bleeding risk compared with ticagrelor plus aspirin dual therapy. These findings were published in the European Heart Journal.

The TWILIGHT study recruited patients (N=6835) who were undergoing drug-eluting stent implantation at 187 sites in 11 countries between 2015 and 2019. Patients were randomized to receive 90 mg twice daily ticagrelor with or without 81-100 mg daily enteric-coated aspirin for 12 months. All patients received the dual therapy for the first 3 months after their successful index PCI. Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 events and ischemic events were assessed for this subanalysis of the role of renal function in bleeding and ischemic risk.

A total of 1111 (16.3%) patients had CKD, among whom 49.9% were randomized to receive the dual therapy. Patients with CKD tended to be older, and more were White compared with the non-CKD patients.

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Bleeding events occurred among 6.8% of the CKD and 5.4% of the non-CKD cohorts (P =.052). Among the CKD cohort, bleeding events occurred among 4.6% of the monotherapy and 9.0% of the dual therapy recipients (hazard ratio [HR], 0.50; 95% CI, 0.31-0.80; P =.004). A similar pattern was observed among the non-CKD cohort (HR, 0.59; 95% CI, 0.47-0.75; P <.001).

Ischemic events occurred among 6.8% of the CKD and 3.4% of the non-CKD cohorts (P <.001). Among the CKD group, 7.9% and 5.7% of the monotherapy and dual therapy recipients had all-cause death, myocardial infarction, or stroke (HR, 1.40; 95% CI, 0.88-2.22; P =.153). Similar patterns were observed among the non-CKD cohort (HR, 0.90; 95% CI, 0.68-1.20; P =.477).

This study was limited by not stratifying patients by CKD status prior to randomization. There were significant differences among CKD treatment groups for gender (P =.014) and rate of insulin-dependent diabetes (P =.020).

These data indicated that ticagrelor monotherapy more effectively reduced risk for bleeding events following PCI among patients with CKD but had little effect on ischemic events.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Stefanini GG, Briguori C, Cao D, et al. Ticagrelor monotherapy in patients with chronic kidney disease undergoing percutaneous coronary intervention: TWILIGHT-CKD. Eur Heart J. 2021;ehab533. doi:10.1093/eurheartj/ehab533