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EuroPCR 2017: TOPIC of the day: should new P2Y12 inhibitors be replaced with Clopidogrel after one month in ACS?

The TOPIC trial included 646 patients without adverse events within the first month after ACS. As pointed out during the ensuing discussion, the results of the TOPIC trial pose a challenge to the current DAPT guidelines.

Reported from EuroPCR 2017, Paris

The rationale of the TOPIC trial was built on the notion that new P2Y12 blockers may be associated with greater ischemic benefit in the early period after ACS, but carry a bleeding hazard in the chronic phase. 

The trial included 646 patients without adverse events within the first month after ACS, who were randomly assigned to either keep taking ticagrelor or prasugrel with aspirin, or to switch to clopidogrel and aspirin. Switching to clopidogrel resulted in the lower rate of death, urgent revascularization, stroke and/or BARC≥2 bleeding at one year (13.4% vs. 26.3%, p<0.01). This difference was mainly driven by a decreased bleeding rate in patients switching to Clopidogrel after one month of ACS, whereas there was no difference in the rate of ischemic events.

As pointed out during the ensuing discussion, the results of the TOPIC trial pose a challenge to the current DAPT guidelines, but the single-center nature of the study and the lack of power to detect mortality difference seem to necessitate further, larger trials in this field.

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