In a 61-patient randomized pilot trial of East-Asian adults with chronic coronary syndrome undergoing elective PCI, half-dose ticagrelor (45 mg twice daily) — whether combined with aspirin or given as monotherapy — produced three times greater platelet inhibition than standard aspirin-plus-clopidogrel DAPT (ΔPRU -188 and -181 vs -60.5; P<0.001). Critically, aspirin added nothing to platelet suppression beyond ticagrelor alone. At 12 months, MACE and bleeding each occurred in one of 17 monotherapy patients (5.9%), with zero stent thromboses or cardiac deaths across all arms.
This preprint, not yet peer-reviewed, enters a crowded but consequential space. Landmark trials like TWILIGHT and TICABUS established aspirin-free ticagrelor monotherapy as viable in acute coronary syndrome, but those designs typically included a DAPT run-in period and used full 90 mg dosing. This pilot is among the first to test aspirin-free half-dose ticagrelor initiated on PCI day in stable, elective patients — a meaningfully different risk profile. The East-Asian focus is clinically relevant: this population carries higher bleeding susceptibility per unit of thrombotic risk, making intensity-matching particularly important. However, with only 17–21 patients per arm, the trial is severely underpowered to detect rare but critical endpoints like stent thrombosis. Pharmacodynamic findings are compelling and biologically coherent, but clinical event data are essentially anecdotal at this scale. Consider this hypothesis-generating, not practice-changing — a well-designed rationale for the adequately powered trial the authors themselves call for.
