Long-Term Ischemic and Bleeding Risk with Extended Dual Antiplatelet Therapy After PCI in Patients with 2018 ESC/EACTS Myocardial Revascularization guideline-endorsed High Ishchemic Risk Features
Presenter
Dr. Haoyu Wang, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
Dr. Haoyu Wang1, Bo Xu2 and Kefei Dou2, (1)Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, (2)Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
Keywords: Chronic Total Occlusion (CTO), Coronary, Drug-eluting Stent (DES), Left Main and Bifurcations and Pharmacotherapy
Background:
The ischemic/bleeding trade-off of extended dual antiplatelet therapy (DAPT) after PCI for patients with high ischemic risk (HIR) as endorsed by 2018 ESC/EACTS myocardial revascularization guidelines remain unknown. We sought to evaluate the benefits and harms of DAPT with beyond 1 year versus ≤ 1-year DAPT on long-term clinical outcomes after PCI with DES among ESC/EACTS guideline-endorsed HIR patients.
Methods:
Patients undergoing coronary stenting between January 2013 and December 2013 from the prospective Fuwai registry were defined as HIR if they met at least 1 ESC/EACTS guideline-endorsed HIR criteria with at least 1 of the following characteristics: diffuse (lesion length ≥ 20 mm) multivessel disease in diabetic patients, CKD (eGFR < 60 mL/min), ≥ 3 stents implanted, ≥ 3 lesions treated, bifurcation with 2 stents implanted, total stent length > 60 mm, treatment of CTO, and history of STEMI. A total of 4578 patients who were at HTR and were events free at 1 year after PCI were evaluated. The primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE) (composite of all-cause death, myocardial infarction, or stroke).
Results:
Median follow-up period was 30 months. > 1-year DAPT with clopidogrel and aspirin significantly reduced the risk of MACCE compared with ≤ 1-year DAPT (1.9% vs. 4.6%; HR: 0.38; 95% CI: 0.27–0.54; P < 0.001), driven by a reduction in all-cause death (0.2% vs. 3.0%; HR, 0.07; 95% CI, 0.03–0.15). Cardiac death and definite/ probable stent thrombosis also occurred less frequently in prolonged DAPT group. BARC type 2, 3, or 5 bleeding occurred similarly between both groups (1.1% vs. 0.9%; HR, 1.11; 95% CI, 0.58–2.13; P = 0.763). Similar results were found using multivariable Cox model, propensity score-matched, and inverse probability of treatment weighting analysis.
Conclusions:
Among patients with ESC-endorsed HIR who were free from major ischemic or bleeding events 1 year after coronary stenting, continued DAPT beyond 1 year might offer better effectiveness in terms of atherothrombotic events and comparable safety in terms of clinically relevant bleeding compared with ≤ 1-year DAPT. ESC-HIR criteria is an important parameter to take into account in tailoring DAPT prolongation.