Aspirin-free ticagrelor treatment for heart attack patients managed without revascularization

Evaluation of an asPirin-free Strategy With ticAgrelor in patieNTs witH a Myocardial Infarction treatEd Medically alONe (PANTHEON)

This trial will test whether taking ticagrelor alone (no aspirin) lowers bleeding without increasing heart problems in adults who had a heart attack and were treated medically without revascularization.

Quick facts

• Phase: PHASE3
• Study type: Interventional
• Enrollment: 2570 (estimated)
• Ages: 18 Years and up
• Sex: All
• Sponsor: Montreal Heart Institute (other)
• Locations: 1 site (Montreal, Quebec)
• Trial ID: NCT07257198 on ClinicalTrials.gov

What this trial studies

This is a phase 3, randomized, placebo-controlled trial comparing ticagrelor monotherapy to standard dual antiplatelet therapy (ticagrelor plus aspirin) for 12 months in patients discharged after a type 1 myocardial infarction managed without revascularization. The trial's co-primary goals are to test whether ticagrelor alone reduces BARC type 2, 3, or 5 bleeding at 12 months and to show non-inferiority for a patient-centered ischemic composite (death, MI, stroke, or coronary revascularization) at 12 months. Secondary endpoints include other bleeding classifications (BARC 3/5, TIMI) and individual ischemic outcomes such as cardiovascular death and any revascularization. Participants receive either ticagrelor plus placebo or ticagrelor plus aspirin and are followed with scheduled study visits through the 12-month period.

Who should consider this trial

Good fit: Adults (≥18) hospitalized for a type 1 MI who had a coronary angiogram and are planned for medical management only (no revascularization), able to attend study visits, and expected to live at least 12 months.

Not a fit: Patients who underwent or require revascularization, have type 2–5 MI or non-ischemic myocardial injury, need chronic oral anticoagulants, or have another clear indication for dual antiplatelet therapy are unlikely to benefit from this strategy.

Why it matters

Potential benefit: If successful, this approach could let some heart attack patients avoid aspirin and experience fewer bleeding complications while keeping similar protection against heart attacks and strokes.

How similar studies have performed: Similar aspirin-withdrawal strategies after PCI (for example TWILIGHT and TICO) have reduced bleeding with preserved ischemic protection, but applying ticagrelor monotherapy specifically to medically managed MI patients is less studied and more novel.

Eligibility criteria

Inclusion criteria:

* Age ≥18 years;
* Hospitalized for type 1 MI, according to the 4th Universal Definition of MI;
* Coronary angiogram performed;
* Planned for medical management alone, without revascularization;
* Willingness to participate and to attend study visits;
* Expected life expectancy ≥12 months.

Exclusion criteria:

* Patients hospitalized for type 2-5 MI, or unstable angina, according to the 4th Universal Definition of MI;
* Patients hospitalized for a STEMI with an acute thrombotic lesion of a major epicardial vessel;
* Elevations in cardiac biomarkers (troponins or CK-MB) that is believed by the investigator not to be of ischemic origin (e.g. myocardial injury, myocarditis, Takotsubo syndrome, etc.);
* Confirmed or suspected spontaneous coronary artery dissection;
* Concomitant indication for chronic oral anticoagulant;
* Concomitant non-coronary indication for dual antiplatelet therapy;
* Use of any non-trial antiplatelet drug that needs to be continued based on the judgement of the treating physician;
* Previous hospitalization for MI, PCI, or CABG within 12 months;
* Known hypersensitivity, intolerance, or contra-indication to ASA or ticagrelor;
* Unsuitability for either randomization treatment, based on the judgement of the treating physician

Where this trial is running

Montreal, Quebec

• Montreal Heart Institute — Montreal, Quebec, Canada (RECRUITING)

Study contacts

• Study coordinator: Guillaume Marquis-Gravel, MD

Conditions: NSTEMI - Non-ST Segment Elevation MI, STEMI, Myocardial Infarction, Dual antiplatelet therapy, NSTEMI, medical treatment, aspirin, ticagrelor