Ischemic and bleeding outcomes by diabetes status in patients receiving ticagrelor monotherapy after percutaneous coronary intervention: an updated meta-analysis

Ticagrelor monotherapy after percutaneous coronary intervention (PCI) has been proposed to reduce bleeding risk while maintaining ischemic protection. The objective of this paper is to describe differences in ischemic and bleeding outcomes between patients with and without diabetes mellitus who were treated with ticagrelor monotherapy following PCI. A systematic review and meta-analysis were conducted using MEDLINE, Scopus, and Cochrane databases through 15th July 2025. Eligible studies included post hoc analyses of randomized trials comparing ticagrelor monotherapy outcomes between diabetic and non-diabetic patients. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Four trials were included with a total population of 18,596. Diabetic patients had significantly higher risk of major adverse cardiovascular events (RR 1.84, 95% CI 1.44-2.36; p<0.00001; I²=37%), all-cause mortality (RR 2.46, 95% CI 1.95-3.10; p<0.00001; I²=0%), cardiac death (RR 3.03, 95% CI 1.23-7.48; p=0.02; I²=23%), stroke (RR 1.71, 95% CI 1.09-2.67; p=0.02; I²=0%), clinically relevant bleeding (RR 1.35, 95% CI 1.15-1.58; p=0.0002; I²=0%) and major bleeding (RR 1.81, 95% CI 1.40-2.34; p<0.00001; I²=1%). Myocardial infarction and stent thrombosis did not differ significantly between groups. We can conclude that among patients treated with ticagrelor monotherapy after PCI, those with diabetes experienced higher ischemic and bleeding event rates than non-diabetic patients. These findings reflect diabetes-associated risk differences within a uniform anti-platelet regimen and should be interpreted as hypothesis-generating.