Dual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary Stenting

Complex percutaneous coronary intervention (PCI) is associated with higher ischemic risk, which can be mitigated by long-term dual antiplatelet therapy (DAPT). However, concomitant high bleeding risk (HBR) may be present, making it unclear whether short- or long-term DAPT should be prioritized. This...

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Veröffentlicht in:Journal of the American College of Cardiology Jg. 73; H. 7; S. 741
Hauptverfasser: Costa, Francesco, Van Klaveren, David, Feres, Fausto, James, Stefan, Räber, Lorenz, Pilgrim, Thomas, Hong, Myeong-Ki, Kim, Hyo-Soo, Colombo, Antonio, Steg, Philippe Gabriel, Bhatt, Deepak L, Stone, Gregg W, Windecker, Stephan, Steyerberg, Ewout W, Valgimigli, Marco
Format: Journal Article
Sprache:Englisch
Veröffentlicht: United States 26.02.2019
Schlagworte:
Aged
Aged, 80 and over
Drug Administration Schedule
Dual Anti-Platelet Therapy
Duration of Therapy
Female
Hemorrhage - epidemiology
Humans
Male
Middle Aged
Myocardial Ischemia - epidemiology
Myocardial Ischemia - therapy
Percutaneous Coronary Intervention - adverse effects
Platelet Aggregation Inhibitors - therapeutic use
Postoperative Complications - epidemiology
Stents
Treatment Outcome
PRECISE-DAPT score
dual antiplatelet therapy
bleeding
complex PCI
coronary stenting
ISSN:1558-3597, 1558-3597
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Zusammenfassung:Complex percutaneous coronary intervention (PCI) is associated with higher ischemic risk, which can be mitigated by long-term dual antiplatelet therapy (DAPT). However, concomitant high bleeding risk (HBR) may be present, making it unclear whether short- or long-term DAPT should be prioritized. This study investigated the effects of ischemic (by PCI complexity) and bleeding (by PRECISE-DAPT [PREdicting bleeding Complications in patients undergoing stent Implantation and SubsequEnt Dual AntiPlatelet Therapy] score) risks on clinical outcomes and on the impact of DAPT duration after coronary stenting. Complex PCI was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Ischemic and bleeding outcomes in high (≥25) or non-high (<25) PRECISE-DAPT strata were evaluated based on randomly allocated duration of DAPT. Among 14,963 patients from 8 randomized trials, 3,118 underwent complex PCI and experienced a higher rate of ischemic, but not bleeding, events. Long-term DAPT in non-HBR patients reduced ischemic events in both complex (absolute risk difference: -3.86%; 95% confidence interval: -7.71 to +0.06) and noncomplex PCI strata (absolute risk difference: -1.14%; 95% confidence interval: -2.26 to -0.02), but not among HBR patients, regardless of complex PCI features. The bleeding risk according to the Thrombolysis In Myocardial Infarction scale was increased by long-term DAPT only in HBR patients, regardless of PCI complexity. Patients who underwent complex PCI had a higher risk of ischemic events, but benefitted from long-term DAPT only if HBR features were not present. These data suggested that when concordant, bleeding, more than ischemic risk, should inform decision-making on the duration of DAPT.
Bibliographie:ObjectType-Article-1
SourceType-Scholarly Journals-1
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ISSN:1558-3597
1558-3597
DOI:10.1016/j.jacc.2018.11.048