BMI and Deescalation From Ticagrelor to Clopidogrel in Patients With Acute Myocardial Infarction
Authors: Bu Seonghyeon , Kim Chan Joon , Lim Sungmin , Jang Jaehyuk , Park Mahn-Won , Choi Ik Jun , Moon Donggyu , Hwang Byung-Hee , Choo Eun Ho , Lee Kwan Yong , Choi Yun Seok , Kim Hee-Yeol , Yoo Ki-Dong , Jeon Doo Soo , Chang Kiyuk ,   TALOS-AMI investigators, Jeong Myung Ho , Park Chul‐Soo , Shin Woo Seung , Kim Dong Bin , Jung Sang Shik , Cho Byung Ryeol , Ko Jin Shin , Kim Won , Huh Seung Ho , Kim Ki Sik , Kim Sang Hyeon , Cho Chang Hyeon , Park Sang Ho , Yoon Myung Ho , Park Jong Sun , Park Kyung Min , Lee Seoung Hwan , Chung Kyung Tae , Do Joon Hyeong , Kim Sang Wook , Baek Joo Yeol , Shim Byung Joo , Sung Ki Chul , Oh Ju Hyun , Cha Kwang Soo , Cho Young Hoon , Jang Jae Sik , Cho Jin Man , Lee Jang Hoon 
Published: February 2025

Importance

The potential benefits of P2Y12 inhibitor deescalation for acute myocardial infarction after percutaneous coronary intervention may be influenced by body mass index (BMI).

Objectives

To investigate the association of BMI on deescalation outcomes after 12 months in patients with acute myocardial infarction after percutaneous coronary intervention who were initially treated with aspirin plus ticagrelor for 1 month, and to assess whether BMI-based switching from aspirin plus ticagrelor (active control strategy) to aspirin plus clopidogrel (deescalation strategy) is associated with individualized benefits.

Design, Setting, and Participants

This study is a post hoc analysis, based on BMI, of data from the TALOS-AMI (Ticagrelor vs Clopidogrel in Stabilized Patients with Acute Myocardial Infarction) randomized clinical trial. Data were collected from February 14, 2014, to December 31, 2018, with follow-up to January 21, 2021. Analyses were conducted from December 1, 2021, to August 21, 2024. Among 2697 trial participants from 32 centers in South Korea, 2686 participants whose BMI data were available were included.

Exposure

All patients received aspirin plus ticagrelor for 1 month after percutaneous coronary intervention. Stabilized patients were then randomized to either the active control or deescalation strategy for an additional 11 months.

Main Outcomes and Measures

The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, and Bleeding Academic Research Consortium bleeding type 2, 3, or 5 at 12 months after percutaneous coronary intervention. The trial compared the active control and deescalation strategies according to BMIs, including an interaction test.

Results

Of the 2686 patients included (mean [SD] age, 60.0 [11.4] years; 2234 [83.2%] male), 2344 (1161 in the deescalation group and 1183 in the active control group) had a BMI less than 28, and 342 (184 in the deescalation group and 158 in the active control group) had a BMI of 28 or greater. The deescalation strategy was associated with significantly reduced composite outcomes compared with the active control strategy in the group with a BMI less than 28 (53 [4.6%] vs 98 [8.3%]; adjusted hazard ratio, 0.54; 95% CI, 0.39-0.76; P &amp;lt; .001), primarily due to fewer bleeding complications. There was no association in the group with a BMI of 28 or greater (6 [3.3%] vs 5 [3.2%]; adjusted hazard ratio, 1.07; 95% CI, 0.33-3.50; P = .91).

Conclusions and Relevance

In this post hoc analysis of the TALOS-AMI randomized clinical trial, in stabilized patients with acute myocardial infarction, an unguided deescalation strategy of switching from ticagrelor to clopidogrel after 1 month was associated with better clinical outcomes in those with lower BMIs.

Trial Registration

ClinicalTrials.gov Identifier: NCT02018055