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

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 (2019). Dual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary Stenting. Journal of the American College of Cardiology, 73(7), pp. 741-754. Elsevier 10.1016/j.jacc.2018.11.048

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BACKGROUND 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. OBJECTIVES 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Cardiovascular Disorders (DHGE) > Clinic of Cardiology

UniBE Contributor:

Räber, Lorenz; Pilgrim, Thomas; Windecker, Stephan and Valgimigli, Marco

Subjects:

600 Technology > 610 Medicine & health

ISSN:

0735-1097

Publisher:

Elsevier

Language:

English

Submitter:

Amanda Valle

Date Deposited:

08 Aug 2019 08:09

Last Modified:

22 Oct 2019 18:00

Publisher DOI:

10.1016/j.jacc.2018.11.048

PubMed ID:

30784667

Uncontrolled Keywords:

PRECISE-DAPT score bleeding complex PCI coronary stenting dual antiplatelet therapy

BORIS DOI:

10.7892/boris.131797

URI:

https://boris.unibe.ch/id/eprint/131797

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