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De Filippo O, Piroli F, Bruno F, Bocchino PP, Saglietto A, Franchin L, Angelini F, Gallone G, Rizzello G, Ahmad M, Gasparini M, Chatterjee S, De Ferrari GM, D'Ascenzo F. De-escalation of dual antiplatelet therapy for patients with acute coronary syndrome after percutaneous coronary intervention: a systematic review and network meta-analysis. BMJ Evid Based Med 2024; 29:171-186. [PMID: 38242567 DOI: 10.1136/bmjebm-2023-112476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/25/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVES To compare dual antiplatelet therapy (DAPT) de-escalation with five alternative DAPT strategies in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). DESIGN We conducted a systematic review and network meta-analysis (NMA). Parallel-arm randomised controlled trials (RCTs) comparing DAPT strategies were included and arms of interest were compared via NMA. Partial ranking of each identified arm and for each investigated endpoint was also performed. SETTING AND PARTICIPANTS Adult patients with ACS (≥18 years) undergoing PCI with indications for DAPT. SEARCH METHODS A comprehensive search covered several databases (PubMed, Embase, Cochrane Central, MEDLINE, Conference Proceeding Citation Index-Science) from inception to 15 October 2023. Medical subject headings and keywords related to ACS, PCI and DAPT interventions were used. Reference lists of included studies were screened. Clinical trials registers were searched for ongoing or unpublished trials. INTERVENTIONS Six strategies were assessed: T1 arm: acetylsalicylic acid (ASA) and prasugrel for 12 months; T2 arm: ASA and low-dose prasugrel for 12 months; T3 arm: ASA and ticagrelor for 12 months; T4 arm: DAPT de-escalation (ASA+P2Y12 inhibitor for 1-3 months, then single antiplatelet therapy with potent P2Y12 inhibitor or DAPT with clopidogrel); T5 arm: ASA and clopidogrel for 12 months; T6 arm: ASA and clopidogrel for 3-6 months. MAIN OUTCOME MEASURES Primary outcome: Cardiovascular mortality. SECONDARY OUTCOMES bleeding events (all, major, minor), stent thrombosis (ST), stroke, myocardial infarction (MI), all-cause mortality, major adverse cardiovascular events (MACE). RESULTS 23 RCTs (75 064 patients with ACS) were included. No differences in cardiovascular mortality, all-cause death, recurrent MI or MACE were found when the six strategies were compared, although with different levels of certainty of evidence. ASA and clopidogrel for 12 or 3-6 months may result in a large increase of ST risk versus ASA plus full-dose prasugrel (OR 2.00, 95% CI 1.14 to 3.12, and OR 3.42, 95% CI 1.33 to 7.26, respectively; low certainty evidence for both comparisons). DAPT de-escalation probably results in a reduced risk of all bleedings compared with ASA plus full-dose 12-month prasugrel (OR 0.49, 95% CI 0.26 to 0.81, moderate-certainty evidence) and ASA plus 12-month ticagrelor (OR 0.52, 95% CI 0.33 to 0.75), while it may not increase the risk of ST. ASA plus 12-month clopidogrel may reduce all bleedings versus ASA plus full-dose 12-month prasugrel (OR 0.66, 95% CI 0.42 to 0.94, low certainty) and ASA plus 12-month ticagrelor (OR 0.70, 95% CI 0.52 to 0.89). CONCLUSIONS DAPT de-escalation and ASA-clopidogrel regimens may reduce bleeding events compared with 12 months ASA and potent P2Y12 inhibitors. 3-6 months or 12-month aspirin-clopidogrel may increase ST risk compared with 12-month aspirin plus potent P2Y12 inhibitors, while DAPT de-escalation probably does not.
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Affiliation(s)
- Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesco Piroli
- S.O.C. Cardiologia Ospedaliera, Presidio Ospedaliero Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Luca Franchin
- Cardiology Department, University Hospital 'Santa Maria della Misericordia', Azienda Sanitaria Universitaria Integrata Friuli Centrale (ASUFC), Udine, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giulia Rizzello
- Dipartimento di Scienze Matematiche (DISMA), Giuseppe Luigi Lagrange, Politecnico di Torino, Torino, Italy
| | | | - Mauro Gasparini
- Dipartimento di Scienze Matematiche (DISMA), Giuseppe Luigi Lagrange, Politecnico di Torino, Torino, Italy
| | - Saurav Chatterjee
- New York Community Hospital, Maimonides Health, Brooklyn, New York, USA
- Zucker School of Medicine, Hempstead, New York, USA
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
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Zhang X, Zhou D, Song S, Huang X, Ding Y, Meng R. Efficacy and Safety of Long-Term Dual Antiplatelet Therapy: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2024; 30:10760296241244772. [PMID: 38571479 PMCID: PMC10993673 DOI: 10.1177/10760296241244772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/04/2024] [Accepted: 03/18/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is a standard therapy in patients with ischemic vascular diseases (IVD) including coronary artery, cerebrovascular and peripheral arterial diseases, although the optimal duration of this treatment is still debated. Previous meta-analyses reported conflicting results about the effects of long-term and short-term as well as non-DAPT use in various clinical settings. Herein, we conducted a comprehensive meta-analysis to assess the efficacy and safety of different durations of DAPT. METHODS We reviewed relevant articles and references from database, which were published prior to April 2023. Data from prospective studies were processed using RevMan5.0 software, provided by Cochrane Collaboration and transformed using relevant formulas. The inclusion criteria involved randomization to long-term versus short-term or no DAPT; the endpoints included at least one of total or cardiovascular (CV) mortalities, IVD recurrence, and bleeding. RESULTS A total of 34 randomized studies involving 141 455 patients were finally included. In comparison with no or short-term DAPT, long-term DAPT reduced MI and stroke, but did not reduce the total and CV mortalities. Meanwhile, bleeding events were increased, even though intracranial and fatal bleedings were not affected. Besides, the reduction of MI and stroke recurrence showed no statistical significance between long-term and short-term DAPT groups. CONCLUSION Long-term DAPT may not reduce the mortality of IVD besides increasing bleeding events, although reduced the incidences of MI and stroke early recurrence to a certain extent and did not increase the risk of fatal intracranial bleeding.
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Affiliation(s)
- Xiaoming Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Da Zhou
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Siying Song
- Division of Neurocritical Care and Emergency Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xiangqian Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China
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3
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De Luca L, Gragnano F, Calabrò P, Huber K. Balancing Benefits and Risks of Oral Antiplatelet Strategies in patients With Coronary Artery Diseases: An Evolving Issue. Curr Probl Cardiol 2023; 48:102025. [PMID: 37553063 DOI: 10.1016/j.cpcardiol.2023.102025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023]
Abstract
Identifying the most appropriate antiplatelet therapy for each patient to prevent ischemic events while minimizing the risk of bleeding is an integral part of the short- and long-term management of patients with coronary artery disease (CAD). This review aims to summarize the available evidence on the contemporary use of P2Y12 inhibitors in CAD patients, focusing on strategies aimed at providing adequate ischemic protection while preventing bleeding risk through dual antiplatelet therapy (DAPT) modulation. Randomized trials and observational studies have been reviewed to determine the most appropriate antiplatelet treatment for CAD patients with different risk profiles. Both ischemic and bleeding events have a significant prognostic impact and should be carefully considered in clinical decision-making. Current guidelines recommend the use of third-generation PY2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel, as a part of DAPT, in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention. Newer P2Y12 inhibitors have a more rapid onset of action and less interindividual variability in platelet inhibition than clopidogrel but are associated with an increased risk of bleeding that may limit their benefit. Importantly, the anti-ischemic benefit of ticagrelor and prasugrel is mainly observed in the first weeks after ACS, whereas clopidogrel seems to provide the best balance between ischemic protection and bleeding as long-term maintenance therapy. These concepts support DAPT modulation after the acute phase, by de-escalating from full-dose to low-dose newer P2Y12 inhibitors, by switching to clopidogrel, or by early withdrawing aspirin to maximize both the efficacy and safety of antiplatelet therapy in patients with CAD.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, A.O. San Camillo-Forlanini, Roma, Italy.
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Kurt Huber
- Department of Cardiology and Intensive Care Medicine, Clinic Ottakring, and Sigmund Freud University, Medical Faculty, Vienna, Austria
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Gorog DA, Ferreiro JL, Ahrens I, Ako J, Geisler T, Halvorsen S, Huber K, Jeong YH, Navarese EP, Rubboli A, Sibbing D, Siller-Matula JM, Storey RF, Tan JWC, Ten Berg JM, Valgimigli M, Vandenbriele C, Lip GYH. De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis. Nat Rev Cardiol 2023; 20:830-844. [PMID: 37474795 DOI: 10.1038/s41569-023-00901-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/22/2023]
Abstract
Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y purinoceptor 12 (P2Y12) inhibitor (prasugrel or ticagrelor) for 12 months. Although this approach reduces ischaemic risk, patients are exposed to a substantial risk of bleeding. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y12 inhibitor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration. Either strategy requires assessment of the ischaemic and bleeding risks of each individual. De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and can be guided by platelet function testing or genotyping. Abbreviation of DAPT duration after 1-6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk. However, these two strategies have not yet been compared in a head-to-head clinical trial. In this Consensus Statement, we summarize the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risks, and provide consensus statements from an international panel of experts to help clinicians to optimize these DAPT approaches for individual patients to improve outcomes.
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Affiliation(s)
- Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital Cologne, Academic Teaching Hospital University of Cologne, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Ludwig-Maximilians University München, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany
| | | | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jack W C Tan
- National Heart Centre Singapore and Sengkang General Hospital, Singapore, Singapore
| | - Jurrien M Ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland
- University of Bern, Bern, Switzerland
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, UK
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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5
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Oliva A, Cao D, Spirito A, Nicolas J, Pileggi B, Kamaleldin K, Vogel B, Mehran R. Personalized Approaches to Antiplatelet Treatment for Cardiovascular Diseases: An Umbrella Review. Pharmgenomics Pers Med 2023; 16:973-990. [PMID: 37941790 PMCID: PMC10629404 DOI: 10.2147/pgpm.s391400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023] Open
Abstract
Antiplatelet therapy is the cornerstone of antithrombotic prevention in patients with established atherosclerosis, since it has been proven to reduce coronary, cerebrovascular, and peripheral thrombotic events. However, the protective effect of antiplatelet agents is counterbalanced by an increase of bleeding events that impacts on patients' mortality and morbidity. Over the last years, great efforts have been made toward personalized antithrombotic strategies according to the individual bleeding and ischemic risk profile, aiming to maximizing the net clinical benefit. The development of risk scores, consensus definitions, and the new promising artificial intelligence tools, as well as the assessment of platelet responsiveness using platelet function and genetic testing, are now part of an integrated approach to tailored antithrombotic management. Moreover, novel strategies are available including dual antiplatelet therapy intensity and length modulation in patients undergoing myocardial revascularization, the use of P2Y12 inhibitor monotherapy for long-term secondary prevention, the implementation of parenteral antiplatelet agents in high-ischemic risk clinical settings, and combination of antiplatelet agents with low-dose factor Xa inhibitors (dual pathway inhibition) in patients suffering from polyvascular disease. This review summarizes the currently available evidence and provides an overview of the principal risk-stratification tools and antiplatelet strategies to inform treatment decisions in patients with cardiovascular disease.
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Affiliation(s)
- Angelo Oliva
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Cardio Center, Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Brunna Pileggi
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Cardiopneumonology, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Karim Kamaleldin
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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Sabouret P, Spadafora L, Fischman D, Ullah W, Zeitouni M, Gulati M, De Rosa S, Savage MP, Costabel JP, Banach M, Biondi-Zoccai G, Galli M. De-escalation of antiplatelet therapy in patients with coronary artery disease: Time to change our strategy? Eur J Intern Med 2023; 110:1-9. [PMID: 36575107 DOI: 10.1016/j.ejim.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/26/2022]
Abstract
Dual antiplatelet therapy (DAPT) is the gold standard after acute coronary syndromes (ACS) or chronic coronary syndromes (CCS) undergoing percutaneous coronary intervention (PCI). Because local and systemic ischemic complications can occur particularly in the early phase (i.e. 1-3 months) after ACS or PCI, the synergistic platelet inhibition of aspirin and a P2Y12 inhibitor is of the utmost importance in this early phase. Moreover, the use of the more potent P2Y12 inhibitors prasugrel and ticagrelor have shown to further reduce the incidence of ischemic events compared to clopidogrel after an ACS. On the other hand, prolonged and potent antiplatelet therapy are inevitably associated with increased bleeding, which unlike thrombotic risk, tends to be stable over time and may outweigh the benefit of reducing ischemic events in these patients. The duration and composition of antiplatelet therapy remains a topic of debate in cardiology due to competing ischemic and bleeding risks, with guidelines and recommendations considerably evolving in the past years. An emerging strategy, called "de-escalation", consisting in the administration of a less intense antithrombotic therapy after a short course of standard DAPT, has shown to reduce bleeding without any trade-off in ischemic events. De-escalation may be achieved with different antithrombotic strategies and can be either unguided or guided by platelet function or genetic testing. The aim of this review is to summarize the evidence and provide practical recommendations on the use of different de-escalation strategies in patients with ACS and CCS.
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Affiliation(s)
- Pierre Sabouret
- Heart Institute, ACTION Study Group-CHU Pitié-Salpétrière, 47-83 Boulevard de l'Hôpital, Paris, France; Collège National des Cardiologues Français (CNCF), Paris, France.
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - David Fischman
- Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Waqas Ullah
- Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Michel Zeitouni
- Heart Institute, ACTION Study Group-CHU Pitié-Salpétrière, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, USA
| | | | | | - Juan Pablo Costabel
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz and Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
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7
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Zhu YX, Liang L, Parasa R, Li Z, Li Q, Chang S, Ma WR, Feng SL, Wang Y, Xu B, Bourantas CV, Zhang YJ. Early vascular healing after neXt-generation drug-eluting stent implantation in Patients with non-ST Elevation acute Coronary syndrome based on optical coherence Tomography guidance and evaluation (EXPECT): study protocol for a randomized controlled trial. Front Cardiovasc Med 2023; 10:1003546. [PMID: 36910518 PMCID: PMC9995825 DOI: 10.3389/fcvm.2023.1003546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Background There is limited evidence about vessel wall healing response following implantation of next-generation drug-eluting stents (DES) in patients admitted with a non-ST elevation acute coronary syndrome (NSTE-ACS). Cumulative data indicate that optical coherence tomography (OCT) imaging can optimize percutaneous coronary intervention results and expedite stent endothelialization in the general population but there is lack of data in NSTE-ACS patients. Methods The EXPECT study is an investigator-initiated, prospective, randomized trial to assess early vascular healing response following next-generation DES implantation in patients admitted with NSTE-ACS based on OCT guidance and evaluation. Sixty patients are randomized at 1:1:1 ratio to OCT-guided percutaneous coronary intervention (PCI) with 3-month follow-up OCT imaging (O3 group, n = 20), to angiography-guided PCI with 3-month follow-up OCT imaging (A3 group, n = 20) and to angiography-guided PCI with 6-month follow-up OCT imaging (A6 group, n = 20). The primary endpoint of the study is stent strut coverage rate at 3- or 6- month follow-up in the studied groups. The secondary endpoints of the study include OCT imaging endpoints, clinical endpoints, and molecular biology endpoints at the different time points. The clinical endpoints comprised of major cardiovascular adverse events and individual components. The molecular biology endpoints comprised of lipid levels and the levels of inflammatory indicators. Discussion The findings of the EXPECT study are anticipated to provide novel insights into vessel wall healing in NSTE-ACS population following implantation of next-generation DES, underscore the value of OCT imaging in expediting strut coverage in this setting, and explore the potential of an early discontinuation of dual antiplatelet therapy (DAPT) in this population. Clinical Trial Registration ClinicalTrials.gov, NCT04375319.
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Affiliation(s)
- Yong-Xiang Zhu
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Li Liang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Ramya Parasa
- Department of Cardiology, Barts Heart Center, Barts Health NHS Trust, London, United Kingdom.,Cardiovascular Devices Hub, Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Zheng Li
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Qian Li
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Shang Chang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Wen-Rui Ma
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Si-Li Feng
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Yang Wang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Christos V Bourantas
- Department of Cardiology, Barts Heart Center, Barts Health NHS Trust, London, United Kingdom.,Cardiovascular Devices Hub, Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Yao-Jun Zhang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
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8
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Luo L, Wang S, Tang K, Yang X, Wu J, Wang D, Xu L, Feng T, Li D, Ran J, Li D, Zhang L, Zhao D. Efficacy and safety of dual antiplatelet therapy after percutaneous coronary drug-eluting stenting: A network meta-analysis. Medicine (Baltimore) 2022; 101:e31158. [PMID: 36281144 PMCID: PMC9592305 DOI: 10.1097/md.0000000000031158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND To evaluate the efficacy and safety of dual antiplatelet regimens after coronary drug-eluting stenting by network meta-analysis (NMA). METHODS PubMed, The Cochrane Library, Embase, and Web of Science databases were electronically searched to collect randomized controlled trials (RCTs) of the comparison of different dual antiplatelet regimens after coronary drug-eluting stenting from inception to September 1st, 2021. Two reviewers independently screened literature, extracted data, and assessed the risk bias of included studies. Stata 16.0 software was used for NMA. RESULTS A total of 27 RCTs involving 79,880 patients were included. The results of NMA: in terms of myocardial infarction (MI), other 3 interventions were higher than the long-term dual antiplatelet therapy (L-DAPT) (the standard dual antiplatelet therapy [Std-DAPT] [odds ratio [OR] = 1.82, 95%confidence interval [CI]: 1.49-2.21), the aspirin monotherapy after short-term dual antiplatelet therapy (S-DAPT + As) (OR = 2.06, 95%CI: 1.57-2.70), the P2Y12 inhibitor monotherapy after short-term dual antiplatelet therapy (S-DAPT + P2Y12) (OR = 1.71, 95%CI: 1.29-2.28)]. In terms of stent thrombosis, other 3 interventions were higher than L-DAPT [Std-DAPT (OR = 2.18, 95%CI: 1.45-3.28), S-DAPT + As (OR = 2.32, 95%CI: 1.52-3.54), S-DAPT + P2Y12 (OR = 2.31, 95%CI: 1.22-4.36)]. There was no statistically significant difference among the 4 interventions in prevention of stroke and all-cause mortality (P > .05). In terms of cardiovascular and cerebrovascular adverse events, other 3 interventions were higher than L-DAPT (Std-DAPT [OR = 1.28, 95%CI: 1.12-1.45], S-DAPT + As [OR = 1.27, 95%CI: 1.09-1.48], S-DAPT + P2Y12 [OR = 1.24, 95%CI: 1.01-1.52]). In terms of safety, bleeding rate of other 3 interventions were lower than L-DAPT (Std-DAPT [OR = 0.67, 95%CI: 0.52-0.85], S-DAPT + As [OR = 0.51, 95%CI: 0.39-0.66], S-DAPT + P2Y12 [OR = 0.36, 95%CI: 0.26-0.49]). Two interventions were lower than L-DAPT (S-DAPT + As [OR = 0.77, 95%CI: 0.65-0.90], S-DAPT + P2Y12 [OR = 0.54, 95%CI: 0.44-0.66]). S-DAPT + As was higher than L-DAPT (OR = 1.42, 95%CI: 1.10-1.83). CONCLUSIONS S-DAPT + P2Y12 has the lowest bleeding risk, while L-DAPT has the highest bleeding risk. In the outcome of MI, stent thrombosis, and cardiovascular and cerebrovascular adverse events, L-DAPT has the best efficacy. In the outcome of stroke and all-cause mortality, the 4 interventions were equally effective.
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Affiliation(s)
- Lin Luo
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Shenglin Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kai Tang
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Xu Yang
- Department of Ophthalmolgy, Sichuan Academy of Medical Sciences, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Jianli Wu
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Dan Wang
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Liqiong Xu
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Tao Feng
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Dejin Li
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Jiuju Ran
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Debo Li
- Department of Neurology, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Li Zhang
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
| | - Dan Zhao
- Department of Cardiovascular, The First People’s Hospital of Shuangliu District, Chengdu, China
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9
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P2Y12 Inhibitor or Aspirin Following Dual Antiplatelet Therapy After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2022; 15:2239-2249. [DOI: 10.1016/j.jcin.2022.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/28/2022] [Accepted: 08/09/2022] [Indexed: 11/06/2022]
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10
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Ullah W, Zahid S, Sandhyavenu H, Faisaluddin M, Khalil F, Pasha AK, Alraies MC, Cuisset T, Rao SV, Sabouret P, Savage MP, Fischman DL. Extended, standard, or De-escalation antiplatelet therapy for patients with coronary artery disease undergoing percutaneous coronary intervention? A trial-sequential, bivariate, influential, and network meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:717-727. [PMID: 35325105 DOI: 10.1093/ehjcvp/pvac020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/02/2022] [Accepted: 03/16/2022] [Indexed: 06/14/2023]
Abstract
AIMS The relative safety and efficacy of de-escalation, extended duration (ED) (>12-months), and standard dual antiplatelet therapy for 12-months (DAPT-12) in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) remains controversial. METHODS AND RESULTS Online databases were queried to identify relevant randomized control trials (RCTs). ED-DAPT, high-potency (HP) DAPT, shorter duration (SD) DAPT, and low-dose (LD) DAPT were compared with DAPT-12. A trial sequential, bivariate, influential, and frequentist network meta-analysis (NMA) was performed to determine the pooled estimates. A total of 30 RCTs comprising 81 208 (40 839 experimental, 40 369 control arm) patients with CAD were included in the quantitative analysis. On NMA, compared with DAPT-12, all types of de-escalation, HP-DAPT-12, and ED-DAPT strategies had a statistically non-significant difference in the incidence of MACE at a median follow-up of 1-year. Similarly, there was no significant difference in the incidence of stroke, stent thrombosis, target lesion revascularization (TLR), target vessel revascularization (TVR), and all-cause mortality between DAPT-12 and all other strategies. The network estimates showed a significantly lower incidence of major bleeding with DAPT for 3-months followed by P2Y12-inhibitor monotherapy (RR 0.62, 95% CI 0.45-0.84), while a higher risk of bleeding with HP-DAPT for 12 months (RR 1.55, 95% CI 1.16-2.06). The net clinical benefit and rankograms also favoured DAPT-3 (P2Y12) and discouraged the use of HP-DAPT-12 and ED-DAPT. A subgroup analysis of 19 RCTs restricted to patients who presented with acute coronary syndrome (ACS) mirrored the findings of pooled analysis. A sensitivity analysis revealed no influence of any individual study or individual strategy on net ischemic estimates. The trial sequential analysis (TSA) illustrated a consistently non-significant difference at the interim analysis of trials, reaching the futility area for MACE, while the cumulative Z-values line surpassed the monitoring boundary as well as the required information size for major bleeding favouring de-escalation strategy. CONCLUSION DAPT for three months followed by ticagrelor-only and use of aspirin + clopidogrel after a short period of high potency DAPT appears to be a safe strategy for treating post-PCI patients. However, given the methodological limitations and inclusion of a small number of trials in novel de-escalation strategies, these findings need validation by future large scale RCTs.
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Affiliation(s)
- Waqas Ullah
- Division of Cardiology, Thomas Jefferson University Hospitals, 111 S 11th Street, Philadelphia, PA 19107, USA
| | - Salman Zahid
- Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621, USA
| | | | | | - Fouad Khalil
- Sanford School of Medicine, University of South Dakota, 1400 West 22nd Street, Sioux Falls, SD 57105, USA
| | - Ahmad K Pasha
- UHS Wilson Hospital, 33-57 Harrison Street, Johnson City, NY 13790, USA
| | - M Chadi Alraies
- Detroit Medical Center, Heart Hospital, 311 Mack Ave, Detroit, MI 48201, USA
| | - Thomas Cuisset
- Aix-Marseille University, 58 Boulevard Charles Livon, 13007 Marseille, France
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, NC, USA
| | - Pierre Sabouret
- Collège National des Cardiologues Français, 13 Rue Niépce, 75014 Paris, France
| | - Michael P Savage
- Division of Cardiology, Thomas Jefferson University Hospitals, 111 S 11th Street, Philadelphia, PA 19107, USA
| | - David L Fischman
- Division of Cardiology, Thomas Jefferson University Hospitals, 111 S 11th Street, Philadelphia, PA 19107, USA
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11
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The Optimal Strategy of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention with Drug-Eluting Stent. J Clin Med 2022; 11:jcm11154465. [PMID: 35956082 PMCID: PMC9370028 DOI: 10.3390/jcm11154465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022] Open
Abstract
Objective: To test the optimal strategy of dual antiplatelet therapy (DAPT) after implantation of drug-eluting stents (DESs) according to specific DAPT time and subsequent monotherapy. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, and Web of Science to identify randomized controlled trials (RCTs). Six DAPT strategies were compared: 1-month DAPT followed by P2Y12 inhibitor monotherapy, 3-month DAPT followed by P2Y12 inhibitor monotherapy, 3-month DAPT followed by aspirin monotherapy, 6-month DAPT followed by aspirin monotherapy, 12-month DAPT, and >12-month DAPT. Pooled odd ratios (ORs) with 95% credible intervals (CrIs) were calculated to summarize the effect of each strategy tested. Results: We identified 24 RCTs containing 81,405 patients. In comparison with 12-month DAPT, 3-month DAPT followed by P2Y12 inhibitor monotherapy reduced net clinical events (OR: 0.72; CrI: 0.55−0.94). Major bleeding (OR: 0.57; CrI: 0.34−1.00) was marginally decreased without impact on ischemic events (OR: 0.93; CrI: 0.68−1.29). Moreover, the benefits of 3-month DAPT (P2Y12 inhibitor) were consistent for male patients with acute coronary disease, young age, complex lesion, single-vessel disease, low body mass index, and without diabetes. Although >12-month DAPT was associated with a lower risk of myocardial infarction (OR: 0.67; CrI: 0.51−0.93), the risk of major bleeding (OR: 1.70; CrI: 1.10−2.70) was increased. Conclusion: Among patients treated with DESs, 3-month DAPT followed by P2Y12 inhibitor monotherapy may be the optimal antiplatelet strategy, while DAPT beyond 1 year reduces myocardial infarction at the expense of increased major bleeding.
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12
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Park DY, An S, Kumar A, Malhotra S, Jolly N, Kaur A, Kattoor A, Doukky R, Kalra A, Vij A. Abbreviated versus Standard Duration of DAPT after PCI: A Systematic Review and Network Meta-analysis. Am J Cardiovasc Drugs 2022; 22:633-645. [PMID: 35781867 DOI: 10.1007/s40256-022-00541-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) is typically continued for 6-12 months depending on clinical presentation. Recent studies have evaluated the safety of shorter durations of DAPT across stable and unstable coronary syndrome but are limited by smaller patient pools and varying indications. METHODS The present study performed a systematic review and network meta-analysis comparing abbreviated (1-3 months) with standard (6-12 months) duration of DAPT. Both conventional and frequentist network meta-analyses with a random-effects model were conducted. RESULTS Seventeen randomized controlled trials, nine of which included 1-3 months of DAPT, were selected. The risks of any bleeding (RR 0.68, 95% CI 0.54-0.85), major bleeding (RR 0.66, 95% CI 0.50-0.86), and net adverse clinical events (NACE) (RR 0.87, 95% CI 0.76-0.99) were lower with abbreviated (1-3 months) than standard-term (6-12 months) DAPT. No significant differences in the risk of myocardial infarction (RR 1.02, 95% CI 0.87-1.18), definite or probable stent thrombosis (RR 1.11, 95% CI 0.83-1.50), and major adverse cardiac events (MACE) (RR 0.96, 95% CI 0.86-1.06) were observed. Network meta-analysis demonstrated lower risk of any bleeding, major bleeding, and NACE with shorter durations of DAPT compared with 12 months. Risks of definite or probable stent thrombosis, myocardial infarction, and MACE were not significantly different. CONCLUSION The results support the growing body of evidence that abbreviated duration (1-3 months) of DAPT may be considered to reduce the risk of bleeding without any differences in myocardial infarction, stent thrombosis, or MACE.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | - Seokyung An
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL, USA.,Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Neeraj Jolly
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Amandeep Kaur
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Ajoe Kattoor
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA.,Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Ankur Kalra
- Section of Invasive and Interventional Cardiology, Cleveland Clinic, Akron, OH, USA
| | - Aviral Vij
- Division of Cardiology, Cook County Health, Chicago, IL, USA. .,Division of Cardiology, Rush Medical College, Chicago, IL, USA.
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13
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Angiolillo DJ, Galli M, Collet JP, Kastrati A, O'Donoghue ML. Antiplatelet therapy after percutaneous coronary intervention. EUROINTERVENTION 2022; 17:e1371-e1396. [PMID: 35354550 PMCID: PMC9896394 DOI: 10.4244/eij-d-21-00904] [Citation(s) in RCA: 90] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022]
Abstract
Antiplatelet therapy is key to reducing local thrombotic complications and systemic ischaemic events among patients undergoing percutaneous coronary interventions (PCI), but it is inevitably associated with increased bleeding. The continuous refinement in stent technologies, together with the high incidence of ischaemic recurrences after PCI and the understanding of prognostic implications associated with bleeding, have led to a substantial evolution in antiplatelet treatment regimens over the past decades. Numerous investigations have been conducted to better stratify patients undergoing PCI according to their ischaemic and bleeding risks and to implement antithrombotic regimens accordingly. Evidence from these investigations have resulted in a number of antithrombotic treatment options as recommended by recent guidelines. In this State-of-the-Art review we provide the rationale, summarise the evidence, and discuss current and future directions of antiplatelet treatment regimens after PCI.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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14
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Alkhalil M, Džavík V, Bhatt DL, Mehran R, Mehta SR. Antiplatelet Therapy in Patients Undergoing Elective Percutaneous Coronary Intervention. Curr Cardiol Rep 2022; 24:277-293. [PMID: 35294730 DOI: 10.1007/s11886-022-01645-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW The evidence for use of dual antiplatelet therapy (DAPT) for patients undergoing percutaneous coronary intervention (PCI) in the elective setting is relatively sparse and is based on data from more than two decades ago. We will review the evidence supporting the use of DAPT with focus on stable patients undergoing elective PCI, including the role of potent P2Y12 inhibitors, modified DAPT durations, and more recently, aspirin discontinuation. RECENT FINDINGS Clopidogrel is the recommended P2Y12 inhibitor in the elective PCI setting. The benefit of more potent P2Y12 inhibitors such as ticagrelor or prasugrel in stable patients is unproven, but their use might be reasonable in those with high clinical or angiographic features of increased ischemic risk without increased risk of bleeding. Moreover, extending DAPT beyond 12 months is associated with a reduction in ischemic events but also increased bleeding. In contrast, shortening DAPT (3-6 months) reduces bleeding compared with 1 year of treatment, but it is also probably associated with increased ischemic events, mainly in higher-risk patients undergoing complex PCI. Recently, early aspirin discontinuation at 3 months (and perhaps as early as 1 month) following PCI reduces bleeding, with no evidence to suggest an increase in ischemic events. Clopidogrel is the P2Y12 inhibitor of choice, while more data are required to support the use of more potent P2Y12 inhibitors in stable patients. The duration of DAPT should be tailored to individual patient ischemic and bleeding risks. New strategies, such as early aspirin discontinuation, are promising to reduce bleeding risk without increase in ischemic risk.
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Affiliation(s)
- Mohammad Alkhalil
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.,Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Vladimír Džavík
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
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15
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Capodanno D, Bhatt DL, Gibson CM, James S, Kimura T, Mehran R, Rao SV, Steg PG, Urban P, Valgimigli M, Windecker S, Angiolillo DJ. Bleeding avoidance strategies in percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:117-132. [PMID: 34426673 DOI: 10.1038/s41569-021-00598-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 02/08/2023]
Abstract
For many years, bleeding has been perceived as an unavoidable consequence of strategies aimed at reducing thrombotic complications in patients undergoing percutaneous coronary intervention (PCI). However, the paradigm has now shifted towards bleeding being recognized as a prognostically unfavourable event to the same extent as having a new or recurrent ischaemic or thrombotic complication. As such, in parallel with progress in device and drug development for PCI, there is clinical interest in developing strategies that maximize not only the efficacy but also the safety (for example, by minimizing bleeding) of any antithrombotic treatment or procedural aspect before, during or after PCI. In this Review, we discuss contemporary data and aspects of bleeding avoidance strategies in PCI, including risk stratification, timing of revascularization, pretreatment with antiplatelet agents, selection of vascular access, choice of coronary stents and antithrombotic treatment regimens.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera italiana (USI), Lugano, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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16
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Knijnik L, Fernandes M, Rivera M, Cardoso R, Goyal A, Liberman H, Sperling LS, McDaniel MC. Meta-Analysis of Duration of Dual Antiplatelet Therapy in Acute Coronary Syndrome Treated With Coronary Stenting. Am J Cardiol 2021; 151:25-29. [PMID: 34049672 DOI: 10.1016/j.amjcard.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
We aimed to evaluate if a shorter course of DAPT followed by P2Y12 inhibitor monotherapy is as effective as a 12-month course with fewer bleeding events. PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials of ACS patients comparing dual antiplatelet therapy (DAPT) for 1 to 3 months followed by a P2Y12 inhibitor to 12-month DAPT. Quality assessment was performed with the Cochrane Collaboration risk of bias assessment tool. Five randomized clinical trials were included, with a total of 18,046 participants. Antiplatelet strategies were aspirin and P2Y12 inhibitor for 12 months compared with aspirin and P2Y12 inhibitor for 1 to 3 months followed by P212 inhibitor alone. Patients randomized to 1 to 3 months of DAPT followed by P2Y12 inhibitor monotherapy had lower rates of major bleeding (1.42% vs 2.53%; OR 0.53; 95% CI 0.42-0.67; p < 0.001; I2 = 0%) and all-cause mortality (1.00% vs 1.42%; OR 0.71; 95% CI 0.53-0.95; p = 0.02; I2=0%) with similar major adverse cardiac events (MACE) (2.66% vs 3.11%; OR 0.86; 95% CI 0.71 - 1.03; p = 0.10; I2 = 0 %) compared to 12 months of DAPT. In conclusion, shorter course of DAPT for 1 to 3 months followed by P2Y12 inhibitor monotherapy reduces major bleeding and all course mortality without increasing major adverse cardiac events compared with traditional DAPT for 12 months.
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17
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De Filippo O, Piroli F, Bruno F, Bocchino PP, Saglietto A, Franchin L, Angelini F, Gallone G, Alabed S, Gasparini M, Ahmad M, De Ferrari GM, D'Ascenzo F. De-escalation of dual antiplatelet therapy for patients with acute coronary syndrome after percutaneous coronary intervention: a network meta-analysis of randomised controlled trials. Hippokratia 2021. [DOI: 10.1002/14651858.cd014813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ovidio De Filippo
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Francesco Piroli
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Francesco Bruno
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Andrea Saglietto
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Luca Franchin
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Filippo Angelini
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Guglielmo Gallone
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease; University of Sheffield; Sheffield UK
| | - Mauro Gasparini
- Dipartimento di Scienze Matematiche (DISMA); Giuseppe Luigi Lagrange, Politecnico di Torino; Torino Italy
| | - Mahmood Ahmad
- Department of Cardiology; Royal Free Hospital, Royal Free London NHS Foundation Trust; London UK
| | | | - Fabrizio D'Ascenzo
- Department of Internal Medicine; Division of Cardiology, University of Turin; Turin Italy
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18
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Li J, He K, Ge J, Li C, Jing Z. Short-term vs long-term dual antiplatelet therapy after drug-eluting stent implantation in patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis. Int J Clin Pract 2021; 75:e13938. [PMID: 33341109 DOI: 10.1111/ijcp.13938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 12/14/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is under controversial. The aim of the present systematic review and meta-analysis was to evaluate the safety and efficacy of short-term (≤6 months) DAPT vs long-term (≥12 months) DAPT after PCI with a drug-eluting stent (DES). METHODS We systematically searched the Cochrane Library, PubMed and Embase databases to identify randomised controlled trials (RCTs) that compared short-term (≤6 months) and long-term (≥12 months) DAPT. The endpoints included major bleeding, any bleeding, death from any cause, cardiac death, myocardial infarction, stroke, stent thrombosis and target vessel revascularisation. The primary outcome was major bleeding. A fixed-effects model was used to calculate the risk ratio (RR) and 95% confidence interval (CI) of each endpoint. RESULTS Eighteen trials involving 57,940 patients were included. Compared with long-term DAPT, short-term DAPT resulted in lower rates of major bleeding [RR 0.75, 95% CI 0.65-0.87, P = .0002] and any bleeding [RR 0.61, 95% CI 0.54-0.69, P < .00001]. No significant difference was observed in the outcomes of death from any cause, cardiac death, myocardial infarction, stroke, stent thrombosis, or target vessel revascularisation. The subgroup analysis according to different DAPT durations, mono antiplatelet therapies (MAPTs), countries and P2Y12 inhibitors produced similar outcomes as comprehensive outcomes. CONCLUSIONS Compared with long-term DAPT, short-term DAPT did not increase the risk of ischemic complications but did reduce the risks of major bleeding and any bleeding by over 25%. This study showed that short-term DAPT could be considered for most patients after DES implantation.
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Affiliation(s)
- Jingxin Li
- Department of Chinese pharmacy, Hebei Maternity Hospital, Shijiazhuang, Hebei Province, China
| | - Ke He
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, China
| | - Jun Ge
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, China
| | - Caixia Li
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, China
| | - Zeng Jing
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, China
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19
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Bularga A, Meah MN, Doudesis D, Shah ASV, Mills NL, Newby DE, Lee KK. Duration of dual antiplatelet therapy and stability of coronary heart disease: a 60 000-patient meta-analysis of randomised controlled trials. Open Heart 2021; 8:e001707. [PMID: 34341097 PMCID: PMC8330558 DOI: 10.1136/openhrt-2021-001707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) has important implications for clinical outcomes in coronary disease. However, the optimal DAPT duration remains uncertain. METHODS AND RESULTS We searched four major databases for randomised controlled trials comparing long-term (≥12 months) with short-term (≤6 months) or shorter (≤3 months) DAPT in patients with coronary syndromes. The primary outcome was all-cause mortality. Secondary outcomes were any bleeding and major bleeding (safety), cardiac death, myocardial infarction, stent thrombosis, revascularisation and stroke (efficacy). Nineteen randomised controlled trials (n=60 111) satisfied inclusion criteria, 8 assessed ≤3 months DAPT. Compared with long-term (≥12 months), short-term DAPT (≤6 months) was associated with a trend towards reduced all-cause mortality (RR: 0.90, 95% CI: 0.80 to 1.01) and significant bleeding reduction (RR: 0.68, 95% CI: 0.55 to 0.83 and RR: 0.66, 95% CI: 0.56 to 0.77 for major and any bleeding, respectively). There were no significant differences in efficacy outcomes. These associations persisted in sensitivity analysis comparing shorter duration DAPT (≤3 months) to long-term DAPT (≥12 months) for all-cause mortality (RR: 0.91, 95% CI: 0.79 to 1.05). In subgroup analysis, short-term DAPT was associated with lower risk of bleeding in patients with acute or chronic coronary syndromes (RR: 0.66, 95% CI: 0.54 to 0.81 and RR: 0.53, 95% CI: 0.33 to 0.65, respectively), but higher risk of stent thrombosis in acute coronary syndrome (RR: 1.49, 95% CI: 1.02 to 2.17 vs RR: 1.25, 95% CI 0.44 to 3.58). CONCLUSION Our meta-analysis suggests that short (≤6 months) and shorter (≤3 months) durations DAPT are associated with lower risk of bleeding, equivalent efficacy and a trend towards lower all-cause mortality irrespective of coronary artery disease stability.
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Affiliation(s)
- Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Mohammed N Meah
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Anoop S V Shah
- Department of Non-Communicable Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
- Usher Institute, University of Edinburgh Division of Health Sciences, Edinburgh, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
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20
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Zheng YY, Wu TT, Guo QQ, Chen Y, Ma X, Ma YT, Zhang JY, Xie X. Long-term dual antiplatelet-induced intestinal injury resulting in translocation of intestinal bacteria into blood circulation increased the incidence of adverse events after PCI in patients with coronary artery disease. Atherosclerosis 2021; 328:1-10. [PMID: 34052667 DOI: 10.1016/j.atherosclerosis.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/04/2021] [Accepted: 04/21/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS The present study aimed to investigate the efficacy and safety of long-term (>18 months) dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). METHODS A total of 3205 coronary artery disease (CAD) patients after PCI from CORFCHD-PCI, a retrospective cohort study (Identifier: ChiCTR-ORC-16010153), were divided into two groups: monotherapy of aspirin or clopidogrel group (SAPT group, n = 2188 and DAPT group, n = 1017) according to whether to discontinue DAPT 18 months after PCI. After propensity matching analysis (PSM), we included 1017 patients in the DAPT group and 1017 patients in the SAPT group. All the patients were followed-up for at least 18 months and the longest follow-up time is 120 months. The primary endpoint was the incidence of major adverse cardiac events (MACEs). The secondary endpoints were the incidence of major adverse cardiovascular and cerebrovascular events (MACEEs) and bleeding events. We also selected 178 patients for detection of claudin-3 and intestinal fatty acid-binding protein and 58 patients for 16s RNA sequencing of whole blood. RESULTS The incidences of MACEs (13.9% vs. 9.0%, p = 0.001) and MACCEs (16.3% vs.10.0%, p < 0.001) were significantly increased in the DAPT group compared to the SAPT group. We also found DAPT increased the bleeding events compared to SAPT (4.6% vs. 2.9%, p = 0.048). Multivariate Cox regression analyses showed that in the DAPT group, cumulative risk of MACCEs increased 1.797 times (HR = 1.797, 95%CI: 1.429-2.226, p < 0.001), MACEs increased 1.737 times (HR = 1.737, 95%CI: 1.360-2.218, p < 0.001) and the bleeding events increased 2.129 times (HR = 2.129, 95%CI: 1.388-3.266, p = 0.001) compared to the SAPT group. We also found the plasma concentrations of claudin-3 and intestinal fatty acid-binding protein (I-FABP) were significantly higher in patients in the DAPT group compared with patients in the SAPT group (both p < 0.001). Correspondingly, the abundance of blood intestinal bacteria in the DAPT group was significantly increased compared to that in the SAPT group (p < 0.001). Furthermore, high-throughput metabolomics analysis suggested that serum level of ceramide (d18:1/16:0) and Neu5Ac was significantly increased in the DAPT group compared to the SAPT group (both p < 0.001). CONCLUSIONS The present study suggests that long-term dual antiplatelet therapy longer than 18 months significantly increases the incidence of both ischemic events and bleeding events after PCI. This preliminary study also indicates that long-term DAPT causes intestinal injury, which induces translocation of intestinal bacteria into the bloodstream.
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Affiliation(s)
- Ying-Ying Zheng
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, 450052, PR China.
| | - Ting-Ting Wu
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China
| | - Qian-Qian Guo
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, 450052, PR China
| | - You Chen
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China
| | - Xiang Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China
| | - Yi-Tong Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China
| | - Jin-Ying Zhang
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, 450052, PR China.
| | - Xiang Xie
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China.
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21
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Efficacy and Safety of Dual Antiplatelet Therapy in Patients Undergoing Coronary Stent Implantation: A Systematic Review and Network Meta-Analysis. J Interv Cardiol 2021; 2021:9934535. [PMID: 34035674 PMCID: PMC8118746 DOI: 10.1155/2021/9934535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/28/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction This network meta-analysis aimed to evaluate the efficacy and safety of different dual antiplatelet therapies (DAPTs) after percutaneous coronary intervention (PCI) with drug-eluting stents (DESs). Methods Randomized controlled trials (RCTs) comparing longer-term (>12 months) DAPT (L-DAPT), 12-month DAPT (DAPT 12Mo), 6-month DAPT (DAPT 6Mo), 3-month DAPT followed by aspirin monotherapy (DAPT 3Mo + ASA), 3-month DAPT followed by a P2Y12 receptor inhibitor monotherapy (DAPT 3Mo + P2Y12), or 1-month DAPT with a P2Y12 receptor inhibitor monotherapy (DAPT 1Mo + P2Y12) were searched. Primary endpoints were all-cause mortality, cardiac death, myocardial infarction (MI), major bleeding, any bleeding, definite or probable stent thrombosis (ST), and net adverse clinical events (NACE). This Bayesian network meta-analysis was performed with the random-effects model. Results Twenty-four RCTs (n = 81339) were included. In comparison with L-DAPT, DAPT 6Mo (OR: 0.50, 95% CI: 0.29–0.83), DAPT 3Mo + P2Y12 (OR: 0.38, 95% CI: 0.18–0.82), DAPT 3Mo + ASA (OR: 0.44, 95% CI: 0.17–0.98), and DAPT 1Mo + P2Y12 (OR: 0.45, 95% CI: 0.14–0.93) were associated with a lower risk of major bleeding. DAPT 3Mo + P2Y12 (OR: 0.58, 95% CI: 0.38–0.88) reduced the risk of any bleeding when compared with DAPT 12Mo. L-DAPT decreased the risk of MI and definite or probable stent ST when compared with DAPT 6Mo. DAPT 3Mo + P2Y12 decreased the risk of NACE in comparison with DAPT 6Mo and DAPT 12Mo. No significant difference in all-cause mortality and cardiac death was observed. In patients with acute coronary syndrome, DAPT 6Mo was comparable to DAPT 12Mo. Conclusion Short-term (1–3 months) DAPT is noninferior to DAPT 6Mo after DESs implantation, while L-DAPT reduces MI and definite or probable ST rates. DAPT 3Mo + P2Y12 might be a reasonable trade-off in patients with high risk of bleeding accompanied by ischemia.
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22
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Gelbenegger G, Erari-Canyurt U, Grafeneder J, Jilma B, Lesiak M, Komosa A, de Caterina R, Postula M, Siller-Matula JM. Optimal duration and combination of antiplatelet therapies following percutaneous coronary intervention: a meta-analysis. Vascul Pharmacol 2021; 138:106858. [PMID: 33753284 DOI: 10.1016/j.vph.2021.106858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/22/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The ideal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) is still unknown. In this meta-analysis, we aimed to compare very short-term (1-3 months), short-term (6 months), standard-term (12 months) and long-term (>12 months) DAPT durations for efficacy and safety. METHODS Overall DAPT comparisons were classified as "any shorter-term"/"any longer-term" DAPT. The primary outcome was a composite of major adverse cardiovascular events (MACE: non-fatal myocardial infarction, non-fatal stroke and cardiovascular death). The primary safety outcome was major bleeding. RESULTS Twenty-six studies comprising 103.394 patients were included. Compared with standard-term DAPT duration, very short-term DAPT duration with subsequent drop of aspirin (RR 1.06, 95% CI, 0.95-1.18, p = 0.26) or drop of the P2Y12 inhibitor (RR 0.92, 95% CI, 0.72-1.16, p = 0.47) was not associated with a higher risk of MACE. Any longer-term compared with any shorter-term DAPT durations led to a significantly lower risk of MACE (RR 0.88, 95% CI, 0.81-0.96, p = 0.002), but a significantly higher risk of BARC 3-5 major bleeding events (RR 1.63, 95% CI, 1.22-2.17, p = 0.001). In the ACS subgroup receiving prasugrel or ticagrelor but not clopidogrel, any longer-term DAPT duration was associated with a significantly lower risk of MACE compared to any shorter-term DAPT duration (RR 0.84, 95% CI, 0.77-0.92, p = 0.0001). CONCLUSION DAPT may be shortened to 1-3 months in patients with low ischemic but high bleeding risk followed by aspirin or P2Y12 monotherapy. Prasugrel or ticagrelor based DAPT may be extended to >12 months in case of high ischemic and low bleeding risk. PROSPERO REGISTRATION NO CRD42020163719.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Ummahan Erari-Canyurt
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jürgen Grafeneder
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Komosa
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Raffaele de Caterina
- University of Pisa, Pisa, Italy; Fondazione Villa Serena per la Ricerca, Città S. Angelo, Pescara, Italy
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Jolanta M Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria; Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland.
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23
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Optimizing Monotherapy Selection, Aspirin Versus P2Y12 Inhibitors, Following Percutaneous Coronary Intervention. Am J Cardiol 2020; 135:154-165. [PMID: 32962804 DOI: 10.1016/j.amjcard.2020.07.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 11/22/2022]
Abstract
Dual antiplatelet therapy (DAPT) reduces ischemic and thrombotic events after percutaneous coronary intervention (PCI). Initial reports of higher myocardial infarction and mortality rates prompted guideline committees to choose 12-month duration of DAPT after PCI. However, higher bleeding rates with DAPT remain a major concern. Since these guidelines were published, there have been improvements in stent design, deployment techniques, and antiplatelet therapies, which have reduced ischemic events. To address bleeding concerns, trials were performed to evaluate the effectiveness of short-duration DAPT. Two main strategies were employed: (1) aspirin monotherapy after a short-duration DAPT, and (2) P2Y12 inhibitor monotherapy after a short-duration DAPT. In this review, we outline all the major trials on short-duration DAPT that have examined the previously mentioned strategies and propose a new individualized treatment algorithm for which monotherapy to choose or remove after PCI. In conclusion, while removing the P2Y12 inhibitor after a short DAPT appears to be safe in the low-risk population, removing aspirin and continuing the P2Y12 inhibitor as monotherapy would be the preferred strategy in intermediate- to high-risk patients to mitigate the bleeding risk.
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24
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Capodanno D, Morice MC, Angiolillo DJ, Bhatt DL, Byrne RA, Colleran R, Cuisset T, Cutlip D, Eerdmans P, Eikelboom J, Farb A, Gibson CM, Gregson J, Haude M, James SK, Kim HS, Kimura T, Konishi A, Leon MB, Magee PFA, Mitsutake Y, Mylotte D, Pocock SJ, Rao SV, Spitzer E, Stockbridge N, Valgimigli M, Varenne O, Windhovel U, Krucoff MW, Urban P, Mehran R. Trial Design Principles for Patients at High Bleeding Risk Undergoing PCI: JACC Scientific Expert Panel. J Am Coll Cardiol 2020; 76:1468-1483. [PMID: 32943165 DOI: 10.1016/j.jacc.2020.06.085] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/26/2020] [Indexed: 01/22/2023]
Abstract
Investigating the balance of risk for thrombotic and bleeding events after percutaneous coronary intervention (PCI) is especially relevant for patients at high bleeding risk (HBR). The Academic Research Consortium for HBR recently proposed a consensus definition in an effort to standardize the patient population included in HBR trials. The aim of this consensus-based document, the second initiative from the Academic Research Consortium for HBR, is to propose recommendations to guide the design of clinical trials of devices and drugs in HBR patients undergoing PCI. The authors discuss the designs of trials in HBR patients undergoing PCI and various aspects of trial design specific to HBR patients, including target populations, intervention and control groups, primary and secondary outcomes, and timing of endpoint reporting.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitario "Policlinico G. Rodolico-San Marco", University of Catania, Catania, Italy.
| | - Marie-Claude Morice
- Cardiovascular European Research Center, Massy, France. https://twitter.com/mc_morice
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts. https://twitter.com/DLBhattMD
| | - Robert A Byrne
- Cardiovascular Research Institute Dublin, Mater Private Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland. https://twitter.com/robebyrne
| | - Roisin Colleran
- Cardiovascular Research Institute Dublin, Mater Private Hospital, Dublin, Ireland; Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Thomas Cuisset
- Département de Cardiologie, Centre Hospitalier Universitaire Timone and Inserm, Inra, Centre de Recherche en Cardiovasculaire et Nutrition, Faculté de Médecine, Aix-Marseille Université, Marseille, France. https://twitter.com/CuissetDr
| | - Donald Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. https://twitter.com/DonaldCutlip
| | | | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Farb
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - C Michael Gibson
- Harvard Medical School, Boston, Massachusetts; Baim Institute for Clinical Research, Brookline, Massachusetts. https://twitter.com/CMichaelGibson
| | - John Gregson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael Haude
- Städtische Kliniken Neuss, Lukaskrankenhaus, Neuss, Germany
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Hyo-Soo Kim
- Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihide Konishi
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Martin B Leon
- Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York. https://twitter.com/MartyMleon
| | - P F Adrian Magee
- U.S. Food and Drug Administration, Silver Spring, Maryland. https://twitter.com/dmylotte
| | - Yoshiaki Mitsutake
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Darren Mylotte
- University Hospital and National University of Ireland, Galway, Ireland
| | - Stuart J Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina. https://twitter.com/SVRaoMD
| | - Ernest Spitzer
- Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands; Cardialysis, Clinical Trial Management and Core Laboratories, Rotterdam, the Netherlands. https://twitter.com/ernest_spitzer
| | | | - Marco Valgimigli
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland. https://twitter.com/vlgmrc
| | - Olivier Varenne
- Service de Cardiologie, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Paris Descartes, Sorbonne Paris-Cité, Paris, France
| | - Ute Windhovel
- Cardiovascular European Research Center, Massy, France. https://twitter.com/Urphi
| | - Mitchel W Krucoff
- Duke Clinical Research Institute, Durham, North Carolina; Duke University Medical Center, Durham, North Carolina. https://twitter.com/mwkrucoff
| | | | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York. https://twitter.com/Drroxmehran
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P2Y12 inhibitor monotherapy versus aspirin monotherapy after short-term dual antiplatelet therapy for percutaneous coronary intervention: Insights from a network meta-analysis of randomized trials. Am Heart J 2020; 227:82-90. [PMID: 32693196 DOI: 10.1016/j.ahj.2020.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND A number of trials have assessed the efficacy and safety of short-term dual antiplatelet therapy (DAPT) in patients who undergo percutaneous coronary intervention (PCI). However, whether to continue aspirin or a P2Y12 inhibitor after a short course of DAPT is actively debated. METHODS PUBMED and EMBASE were searched through March 2020 for randomized controlled trials evaluating short-term DAPT (≤6 months) when compared with longer-term (≥12 months) DAPT among patients undergoing PCI. The ischemic outcomes were all-cause death, myocardial infarction, stent thrombosis, and stroke. The safety outcome was major and/or clinically relevant bleeding. The primary objective was to investigate the outcomes with aspirin monotherapy (Aspirin group) versus P2Y12 inhibitor monotherapy (P2Y12i group) after short-term DAPT. RESULTS Our search identified 17 eligible trials enrolling a total of 54,625 patients comparing different DAPT duration. Either of the 2 monotherapy groups did not increase the risk of ischemic outcomes when compared with the long-term DAPT group, without difference between the Aspirin versus the P2Y12i groups. However, both monotherapy groups significantly reduced bleeding when compared with long-term DAPT (Aspirin group: hazard ratio [95% CI]: 0.62 [0.45-0.86], P=.004 and P2Y12i group: 0.68 [0.50-0.93], P=.015). There was no difference in bleeding between the Aspirin versus P2Y12i groups (hazard ratio=0.91 [0.58-1.43], P=.70). CONCLUSIONS Among patients undergoing PCI, short-term DAPT with continuation of either aspirin or P2Y12i reduced bleeding without increasing ischemic outcomes when compared with long-term DAPT. The choice of antiplatelet therapy after short-term DAPT should be evaluated in well-powered trials.
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Khan SU, Singh M, Valavoor S, Khan MU, Lone AN, Khan MZ, Khan MS, Mani P, Kapadia SR, Michos ED, Stone GW, Kalra A, Bhatt DL. Dual Antiplatelet Therapy After Percutaneous Coronary Intervention and Drug-Eluting Stents: A Systematic Review and Network Meta-Analysis. Circulation 2020; 142:1425-1436. [PMID: 32795096 PMCID: PMC7547897 DOI: 10.1161/circulationaha.120.046308] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention with drug-eluting stents remains uncertain. We compared short-term (<6-month) DAPT followed by aspirin or P2Y12 inhibitor monotherapy; midterm (6-month) DAPT; 12-month DAPT; and extended-term (>12-month) DAPT after percutaneous coronary intervention with drug-eluting stents. METHODS Twenty-four randomized, controlled trials were selected using Medline, Embase, Cochrane library, and online databases through September 2019. The coprimary end points were myocardial infarction and major bleeding, which constituted the net clinical benefit. A frequentist network meta-analysis was conducted with a random-effects model. RESULTS In 79 073 patients, at a median follow-up of 18 months, extended-term DAPT was associated with a reduced risk of myocardial infarction in comparison with 12-month DAPT (absolute risk difference, -3.8 incident cases per 1000 person-years; relative risk, 0.68 [95% CI, 0.54-0.87]), midterm DAPT (absolute risk difference, -4.6 incident cases per 1000 person-years; relative risk, 0.61 [0.45-0.83]), and short-term DAPT followed by aspirin monotherapy (absolute risk difference, -6.1 incident cases per 1000 person-years; relative risk, 0.55 [0.37-0.83]), or P2Y12 inhibitor monotherapy (absolute risk difference, -3.7 incident cases per 1000 person-years; relative risk, 0.69 [0.51-0.95]). Conversely, extended-term DAPT was associated with a higher risk of major bleeding than all other DAPT groups. In comparison with 12-month DAPT, no significant differences in the risks of ischemic end points or major bleeding were observed with midterm or short-term DAPT followed by aspirin monotherapy, with the exception that short-term DAPT followed by P2Y12 inhibitor monotherapy was associated with a reduced risk of major bleeding. There were no significant differences with respect to mortality between the different DAPT strategies. In acute coronary syndrome, extended-term in comparison with 12-month DAPT was associated with a reduced risk of myocardial infarction without a significant increase in the risk of major bleeding. CONCLUSIONS The present network meta-analysis suggests that, in comparison with 12-month DAPT, short-term DAPT followed by P2Y12 inhibitor monotherapy reduces major bleeding after percutaneous coronary intervention with drug-eluting stents, whereas extended-term DAPT reduces myocardial infarction at the expense of more bleeding events.
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Affiliation(s)
- Safi U Khan
- Department of Medicine, West Virginia University, Morgantown (S.U.K., S.V., M.U.K., A.N.L., M.Z.K.)
| | - Maninder Singh
- Department of Cardiovascular Medicine, Guthrie Health System/Robert Packer Hospital, Sayre, PA (M.S.)
| | - Shahul Valavoor
- Department of Medicine, West Virginia University, Morgantown (S.U.K., S.V., M.U.K., A.N.L., M.Z.K.)
| | - Muhammad U Khan
- Department of Medicine, West Virginia University, Morgantown (S.U.K., S.V., M.U.K., A.N.L., M.Z.K.)
| | - Ahmad N Lone
- Department of Medicine, West Virginia University, Morgantown (S.U.K., S.V., M.U.K., A.N.L., M.Z.K.)
| | - Muhammad Zia Khan
- Department of Medicine, West Virginia University, Morgantown (S.U.K., S.V., M.U.K., A.N.L., M.Z.K.)
| | - Muhammad Shahzeb Khan
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL (M.S.K.)
| | - Preethi Mani
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, OH (P.M., S.R.K., A.K.)
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, OH (P.M., S.R.K., A.K.)
| | - Erin D Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (E.D.M.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, and the Cardiovascular Research Foundation (G.W.S.)
| | - Ankur Kalra
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, OH (P.M., S.R.K., A.K.).,Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, OH (A.K.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
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The optimal duration of dual antiplatelet therapy in East Asian patients undergoing percutaneous coronary intervention with drug-eluting stents: a meta-analysis of randomized trials. Coron Artery Dis 2020; 32:119-130. [PMID: 32639246 DOI: 10.1097/mca.0000000000000921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The optimal duration of dual antiplatelet therapy (DAPT) is still controversial among East Asians. This meta-analysis was designed to evaluate the efficacy and safety of short-term (≤6 months) vs. long-term (≥12 months) DAPT in East Asians undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES). METHODS PubMed, Embase, Web of Science and the Cochrane Library were searched for articles published up to 30 March 2020. Then meta-analysis was performed using RevMan 5.3 software. RESULTS Nine studies with a total of 20 177 East Asian patients were included in this meta-analysis. In East Asian patients, short-term DAPT was associated with a lower incidence of major bleeding [odds ratio (OR) = 0.70, 95% confidence interval (CI) (0.49, 0.99), P = 0.04]. In the newer-generation DES subgroup, short-term DAPT was no less effective than long-term DAPT and resulted in a lower incidence of major bleeding [OR = 0.69, 95% CI (0.49, 0.98), P = 0.04]. In the subgroup of patients with acute coronary syndrome, there was no significant difference in the incidence of cardiac death, net adverse clinical and cerebral events (NACCE) and major bleeding between short-term and long-term DAPT. It was worth noting that in the subgroup of patients with diabetes mellitus, short-term DAPT was associated with a higher incidence of myocardial infarction [OR = 2.64, 95% CI (1.19, 5.88), P = 0.02] and NACCE [OR = 1.92, 95% CI (1.07, 3.43), P = 0.03]. CONCLUSION The short-term DAPT (≤6 months) might be a better choice for East Asian patients undergoing PCI with DES, especially the newer-generation DES. However, for high-risk patients such as diabetes, the analysis supported the longer DAPT.
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Jang JY, Jung HW, Lee BK, Shin DH, Kim JS, Hong SJ, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Park KW, Gwon HC, Kim HS, Kwon HM, Jang Y. Impact of PRECISE-DAPT and DAPT Scores on Dual Antiplatelet Therapy Duration After 2nd Generation Drug-Eluting Stent Implantation. Cardiovasc Drugs Ther 2020; 35:343-352. [PMID: 32588238 DOI: 10.1007/s10557-020-07008-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Determining the optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is an important clinical issue. We evaluated the effects of ischemia (by DAPT score) and bleeding (by PRECISE-DAPT score), as well as the impact of DAPT duration, on clinical outcomes. METHODS From pooled analysis of four randomized clinical trials, 5131 patients undergoing second-generation DES implantation were randomized to short-duration (n = 2575; ≤ 6 months) or standard-duration (n = 2556; ≥ 12 months) DAPT groups. This population was further divided into four subgroups according to PRECISE-DAPT (high bleeding risk ≥ 25) and DAPT (high ischemic risk ≥ 2) scores. RESULTS Net clinical outcomes (1.3% vs. 1.3%; p = 0.89) and ischemic events (5.0% vs. 4.5%; p = 0.44) did not differ between the two duration groups, although bleeding events were more frequent in patients with standard-duration DAPT (0.4% vs. 0.9%; p = 0.04). Standard-duration DAPT was associated with fewer ischemic events (6.9% vs. 4.0%; p = 0.02) and no increase in bleeding events only among patients at low bleeding risk and high ischemic risk. The other groups show no differences in net clinical outcomes, ischemic events, or bleeding events according to DAPT duration. CONCLUSION Compared with short-duration DAPT, standard-duration DAPT was associated with similar net clinical outcomes and ischemic events, but more bleeding events at 12 months after second-generation DES implantation. However, standard-duration DAPT reduced ischemic events without increasing bleeding events among patients at low bleeding and high ischemic risk. When determining DAPT duration, considering both ischemic and bleeding risk can help optimize patient benefits. CLINICAL TRIAL REGISTRATION EXCELLENT (NCT00698607), RESET (NCT01145079), IVUS-XPL (NCT01308281), OPTIMA-C (NCT03056118).
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Affiliation(s)
- Ji-Yong Jang
- National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Hae Won Jung
- Daegu Catholic University Medical Center, Daegu, South Korea
| | - Byoung-Kwon Lee
- Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, South Korea.
| | - Dong-Ho Shin
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Jung-Sun Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Chul-Min Ahn
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Young-Guk Ko
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Donghoon Choi
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyung Woo Park
- Seoul National University Hospital School of Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyeon-Cheol Gwon
- Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, South Korea
| | - Hyo-Soo Kim
- Seoul National University Hospital School of Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyuck Moon Kwon
- Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, South Korea
| | - Yangsoo Jang
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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Nakamura M, Kimura K, Kimura T, Ishihara M, Otsuka F, Kozuma K, Kosuge M, Shinke T, Nakagawa Y, Natsuaki M, Yasuda S, Akasaka T, Kohsaka S, Haze K, Hirayama A. JCS 2020 Guideline Focused Update on Antithrombotic Therapy in Patients With Coronary Artery Disease. Circ J 2020; 84:831-865. [DOI: 10.1253/circj.cj-19-1109] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken Kozuma
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Yoshihisa Nakagawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Shiga University of Medical Science
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Kazuo Haze
- Department of Cardiology, Kashiwara Municipal Hospital
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30
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Palmerini T, Bruno AG, Gilard M, Morice MC, Valgimigli M, Montalescot G, Collet JP, Della Riva D, Bacchi-Reggiani ML, Steg PG, Diallo A, Vicaut E, Helft G, Nakamura M, Généreux P, Vahl TP, Stone GW. Risk-Benefit Profile of Longer-Than-1-Year Dual-Antiplatelet Therapy Duration After Drug-Eluting Stent Implantation in Relation to Clinical Presentation. Circ Cardiovasc Interv 2020; 12:e007541. [PMID: 30871353 DOI: 10.1161/circinterventions.118.007541] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND We sought to determine whether the risks and benefits of prolonging dual-antiplatelet therapy (DAPT) beyond 1 year after drug-eluting stent implantation depend on clinical presentation in a meta-analysis of randomized controlled trials. METHODS AND RESULTS Randomized controlled trials comparing ≤1- versus >1-year DAPT after drug-eluting stent placement were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. The primary efficacy end point was myocardial infarction, whereas the primary safety end point was major bleeding. Net clinical benefit was defined as the composite of myocardial infarction or major bleeding. Outcomes were analyzed according to patient presentation with stable ischemic heart disease versus acute coronary syndromes. The meta-analysis included 6 trials with a total of 21 457 patients, including 14 132 with stable ischemic heart disease and 7325 with acute coronary syndrome. After a median follow-up of 19.5 months, ≤1-year DAPT was associated with higher rates of myocardial infarction compared with >1-year DAPT (hazard ratio [HR], 1.63; 95% CI, 1.37-1.95), with no interaction apparent between treatment effect and clinical presentation. Shorter DAPT was associated with reduced rates of major bleeding compared with longer DAPT (HR, 0.64; 95% CI, 0.42-0.99) with no significant interaction between treatment effect and clinical presentation. However, a net clinical benefit of >1-year DAPT was present in patients with acute coronary syndrome (HR of shorter versus longer DAPT, 1.59; 95% CI, 1.24-2.02) but not in those with stable ischemic heart disease (HR, 1.15; 95% CI, 0.89-1.51; Pinteraction=0.04). Shorter DAPT was also associated with lower rates of noncardiac mortality compared with longer DAPT (HR, 0.71; 95% CI, 0.52-0.96), with no significant interaction between treatment effect and clinical presentation ( Pinteraction=0.12). CONCLUSIONS Compared with ≤1-year DAPT, >1-year DAPT reduces the risk of myocardial infarction but increases the risk of major bleeding and noncardiac mortality. A net clinical benefit of extended DAPT was apparent for patients with acute coronary syndrome but not for those with stable ischemic heart disease.
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Affiliation(s)
- Tullio Palmerini
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P., A.G.B., D.D.R., M.L.B.-R.)
| | - Antonio G Bruno
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P., A.G.B., D.D.R., M.L.B.-R.)
| | - Martine Gilard
- Department of Cardiology, Brest University, France (M.G.)
| | - Marie-Claude Morice
- Générale de Santé, Institut Cardiovasculaire Paris Sud, Massy, France (M.-C.M.)
| | | | | | | | - Diego Della Riva
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P., A.G.B., D.D.R., M.L.B.-R.)
| | | | - Philippe Gabriel Steg
- ACTION Study Group, Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (P.G.S.).,Hopital Bichat (P.G.S.), Assistance Publique-Hopitaux de Paris, France
| | - Abdourahmane Diallo
- Unite de Recherche Clinique Lariboisière St. Louis Hopital Fernand Widal (A.D., E.V.), Assistance Publique-Hopitaux de Paris, France
| | - Eric Vicaut
- Unite de Recherche Clinique Lariboisière St. Louis Hopital Fernand Widal (A.D., E.V.), Assistance Publique-Hopitaux de Paris, France
| | - Gerard Helft
- Institut de Cardiologie, Hopital Pitie-Salpetriere (G.H.), Assistance Publique-Hopitaux de Paris, France.,Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan (G.H.)
| | - Masato Nakamura
- Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (M.N., P.G.)
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (M.N., P.G.).,Cardiovascular Research Foundation, New York, NY (P.G., T.P.V., G.W.S.)
| | - Torsten P Vahl
- Cardiovascular Research Foundation, New York, NY (P.G., T.P.V., G.W.S.).,NewYork-Presbyterian Hospital/Columbia University Medical Center NY (T.P.V., G.W.S.)
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York, NY (P.G., T.P.V., G.W.S.).,NewYork-Presbyterian Hospital/Columbia University Medical Center NY (T.P.V., G.W.S.)
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Jang JY, Lee BK, Kim JS, Shin DH, Hong SJ, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Park KW, Gwon HC, Kim HS, Kwon HM, Jang Y. Efficacy and Safety of Guideline-Recommended Risk Score-Directed Dual Antiplatelet Therapy After 2nd-Generation Drug-Eluting Stents. Circ J 2020; 84:161-168. [PMID: 31839621 DOI: 10.1253/circj.cj-19-0667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Evaluate the safety and efficacy of guideline-recommended risk score-directed dual antiplatelet therapy (GD-DAPT) based on THE PRECISE-DAPT score after 2nd-generation drug-eluting stent (DES) implantation.Methods and Results:We analyzed 5,131 patients pooled from 4 clinical trials. Patients were divided into 3 groups according to current recommendations on the duration of DAPT and their actual DAPT duration: GD-DAPT (n=2,183), shorter DAPT (n=1,540), longer DAPT (n=1,408). The primary endpoint was the rate of net adverse clinical events (NACE) during the first 12 months. The secondary endpoints were ischemic or bleeding events. Overall, GD-DAPT did not affect NACE (1.2% vs. 1.2% for shorter DAPT and 1.7% for longer DAPT) or bleeding events (0.6% vs. 0.5% and 0.9%), and there were fewer ischemic events (2.8% vs. 4.4% and 4.0%, P=0.03) than with shorter DAPT. Especially in acute coronary syndrome (ACS) patients, GD-DAPT had fewer NACE (1.5% vs. 1.4% and 4.2%; P=0.006) and bleeding events (0.8% vs. 0.5% and 2.8%; P=0.001) than longer DAPT as well as fewer ischemic events (2.8% vs. 4.4% and 4.7%; P=0.03) than shorter DAPT. CONCLUSIONS GD-DAPT did not affect NACE or bleeding events and reduced the number of ischemic events at 12 months compared with shorter DAPT. For ACS, GD-DAPT was associated with favorable outcomes compared with non-GD-DAPT. Therefore, GD-DAPT may optimize efficacy and safety.
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Affiliation(s)
- Ji-Yong Jang
- Division of Cardiology, National Health Insurance Service Ilsan Hospital
| | - Byoung-Kwon Lee
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Dong-Ho Shin
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine.,Cardiovascular Research Institute, Yonsei University College of Medicine
| | - Kyung Woo Park
- Division of Cardiology, Seoul National University Hospital School of Medicine, Seoul National University College of Medicine
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Samsung Medical Centre, Sungkyunkwan University College of Medicine
| | - Hyo-Soo Kim
- Division of Cardiology, Seoul National University Hospital School of Medicine, Seoul National University College of Medicine
| | - Hyuck Moon Kwon
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine.,Cardiovascular Research Institute, Yonsei University College of Medicine
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Duration of Dual Antiplatelet Therapy and Late Stent Thrombosis Following Percutaneous Coronary Intervention with Second-Generation Drug-Eluting Stents: A Simple Meta-Analysis of Randomized Controlled Trials. Adv Ther 2019; 36:3166-3173. [PMID: 31535329 PMCID: PMC6822788 DOI: 10.1007/s12325-019-01091-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Indexed: 02/06/2023]
Abstract
Introduction The aim of this simple meta-analysis was to systematically compare the occurrence of late and very late stent thrombosis with a short versus a longer duration of dual anti-platelet therapy (DAPT) use following the implantation of second-generation drug-eluting stents (DES). Methods Randomized controlled trials that compared short- and long-term DAPT use following percutaneous coronary intervention (PCI) with DES and that reported late (> 30 days but < 1 year) and very late (> 1 year) stent thromboses were searched from the bibliographic database of life sciences and biomedical information, which is also known as MEDLINE, as well as other searched databases including EMBASE, the Cochrane Central and http://www.ClinicalTrials.com. Statistical analysis was carried out using RevMan software [odds ratios (OR) and 95% confidence intervals (CIs) represented the results]. Results This simple analysis consisted of five randomized controlled trials with a total of 7142 patients. The current results showed no significant difference in late stent thrombosis associated with a shorter or longer duration of DAPT use (OR 0.98, 95% CI 0.30–3.18; P = 0.97, I2 = 0%). The result for very late stent thrombosis was also not significantly different (OR 0.30, 95% CI 0.03–2.95; P = 0.31). Conclusions This simple analysis showed no impact of DAPT duration on the occurrence of late and very late stent thrombosis. Similar late and very late stent thrombosis rates were observed with 6-month versus 12-month duration of DAPT use following PCI with second-generation DES.
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Yin SHL, Xu P, Wang B, Lu Y, Wu QY, Zhou ML, Wu JR, Cai JJ, Sun X, Yuan H. Duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stent: systematic review and network meta-analysis. BMJ 2019; 365:l2222. [PMID: 31253632 PMCID: PMC6595429 DOI: 10.1136/bmj.l2222] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of standard term (12 months) or long term (>12 months) dual antiplatelet therapy (DAPT) versus short term (<6 months) DAPT after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). DESIGN Systematic review and network meta-analysis. DATA SOURCES Relevant studies published between June 1983 and April 2018 from Medline, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, ClinicalTrials.gov, and Clinicaltrialsregister.eu. REVIEW METHODS Randomised controlled trials comparing two of the three durations of DAPT (short term, standard term, and long term) after PCI with DES were included. The primary study outcomes were cardiac or non-cardiac death, all cause mortality, myocardial infarction, stent thrombosis, and all bleeding events. RESULTS 17 studies (n=46 864) were included. Compared with short term DAPT, network meta-analysis showed that long term DAPT resulted in higher rates of major bleeding (odds ratio 1.78, 95% confidence interval 1.27 to 2.49) and non-cardiac death (1.63, 1.03 to 2.59); standard term DAPT was associated with higher rates of any bleeding (1.39, 1.01 to 1.92). No noticeable difference was observed in other primary endpoints. The sensitivity analysis revealed that the risks of non-cardiac death and bleeding were further increased for ≥18 months of DAPT compared with short term or standard term DAPT. In the subgroup analysis, long term DAPT led to higher all cause mortality than short term DAPT in patients implanted with newer-generation DES (1.99, 1.04 to 3.81); short term DAPT presented similar efficacy and safety to standard term DAPT with acute coronary syndrome (ACS) presentation and newer-generation DES placement. The heterogeneity of pooled trials was low, providing more confidence in the interpretation of results. CONCLUSIONS In patients with all clinical presentations, compared with short term DAPT (clopidogrel), long term DAPT led to higher rates of major bleeding and non-cardiac death, and standard term DAPT was associated with an increased risk of any bleeding. For patients with ACS, short term DAPT presented similar efficacy and safety with standard term DAPT. For patients implanted with newer-generation DES, long term DAPT resulted in more all cause mortality than short term DAPT. Although the optimal duration of DAPT should take personal ischaemic and bleeding risks into account, this study suggested short term DAPT could be considered for most patients after PCI with DES, combining evidence from both direct and indirect comparisons. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018099519.
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Affiliation(s)
- Shang-He-Lin Yin
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Peng Xu
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Bian Wang
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Yao Lu
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Qiao-Yu Wu
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Meng-Li Zhou
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Jun-Ru Wu
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Jing-Jing Cai
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xin Sun
- Chinese Evidence-based Medicine Centre and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, Sichuan, China
| | - Hong Yuan
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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Barbarawi M, Kheiri B, Zayed Y, Aburahma A, Osman M, Barbarawi O, Hicks M, Hassan M, Alkotob ML, Bachuwa G. Best duration of dual antiplatelet therapy after drug-eluting stent implantation: an updated network meta-analysis of randomized controlled trials. J Community Hosp Intern Med Perspect 2019; 9:9-17. [PMID: 30788068 PMCID: PMC6374928 DOI: 10.1080/20009666.2018.1562853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 12/18/2018] [Indexed: 01/28/2023] Open
Abstract
Background: Drug-eluting stent(DES) implantation is the main interventional treatment for coronary artery disease, and dual antiplatelet therapy(DAPT) remains the gold standard strategy to prevent ischemic events. However, the optimal duration of DAPT after DES implantation remains controversial. Therefore, we aimed to evaluate the best duration of DAPT following DES implantation. Method: We searched PubMed, Embase, Cochrane Library, and clinicaltrials.gov for all randomized clinical trials(RCTs) that compared different durations of DAPT after DES implantation. Major adverse cardiac events(MACE) and major bleeding were the primary and secondary outcomes, respectively. Results: We included 16 RCTs (n = 42,993). The mean age of included patients was 63.1 ± 10.1. The primary outcome was statistically significant for lower MACE in patients who received DAPT for 24-48 months (mo) following DES when compared with those who received 3-6 mo of DAPT (odds ratio [OR] 0.75; 95% credible interval [CI] 0.58-0.97). There was nonstatistically significant difference in MACE when comparing those who received 12 mo of DAPT to those taking either 3-6 mo of DAPT (OR 0.86; 95% CI 0.69-1.08) or 24-48 mo of DAPT (OR 0.87; 95% CI 0.72-1.05). In contrast, major bleeding was significantly lower in those who received 3-6 mo of DAPT (OR 0.32; 95% CI 0.17-0.54) and 12 mo of DAPT (OR 0.43; 95% CI 0.27-0.63) than in those who received 24-48 mo of DAPT. Conclusion: In patients who undergo DES implantation, a longer duration of DAPT is associated with lower MACE, despite the increased risk of major bleeding events. Therefore, individualizing the duration of DAPT after DES according to the patient's risk of bleeding and recurrent ischemia is recommended.
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Affiliation(s)
- Mahmoud Barbarawi
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Babikir Kheiri
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Yazan Zayed
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ahmed Aburahma
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Mohammed Osman
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Owais Barbarawi
- Department of Internal Medicine, Mutah University, Al-Karak, Jordan
| | - Michael Hicks
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Mustafa Hassan
- Department of Cardiology, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Mohammad L Alkotob
- Department of Cardiology, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
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ACC/AHA Versus ESC Guidelines on Dual Antiplatelet Therapy. J Am Coll Cardiol 2018; 72:2915-2931. [DOI: 10.1016/j.jacc.2018.09.057] [Citation(s) in RCA: 204] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/05/2018] [Accepted: 09/08/2018] [Indexed: 01/25/2023]
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Costa F, Valgimigli M. The optimal duration of dual antiplatelet therapy after coronary stent implantation: to go too far is as bad as to fall short. Cardiovasc Diagn Ther 2018; 8:630-646. [PMID: 30498687 PMCID: PMC6232356 DOI: 10.21037/cdt.2018.10.01] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 09/30/2018] [Indexed: 01/01/2023]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is key for secondary prevention of recurrent coronary ischemic events and stent thrombosis. For this purpose, DAPT showed superior efficacy compared to aspirin alone, but it is also associated with an increased risk of major, and potentially fatal, bleeding. Hence, while secondary prevention with aspirin monotherapy is generally maintained for an indefinite period, the duration of DAPT after the index event is still debated. Multiple trials have challenged the guideline recommended standard of care of 12 months of DAPT duration. These studies tested on one side a treatment reduction to 6 or 3 months, and on the other side an extension of treatment beyond 12 months in order to define the optimal DAPT duration maximizing the anti-ischemic protection and minimizing bleeding. In this document we sought to summarize the existing evidence from more than 18 randomized controlled trials in the field, and discuss the benefit and risks of prolonging/shortening DAPT duration. In addition, a specific focus on treatment individualization will outline the current, evidence-based, decision-making process for optimal DAPT duration selection after coronary stenting.
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Affiliation(s)
- Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, Messina, Italy
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
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Bittl JA, He Y, Kaul S. DAPT rules. EUROINTERVENTION 2018; 13:1864-1868. [PMID: 29555616 DOI: 10.4244/eijv13i16a303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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