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Yamamoto K, Watanabe H, Morimoto T, Obayashi Y, Natsuaki M, Domei T, Yamaji K, Suwa S, Isawa T, Watanabe H, Yoshida R, Sakamoto H, Akao M, Hata Y, Morishima I, Tokuyama H, Yagi M, Suzuki H, Wakabayashi K, Suematsu N, Inada T, Tamura T, Okayama H, Abe M, Kawai K, Nakao K, Ando K, Tanabe K, Ikari Y, Morino Y, Kadota K, Furukawa Y, Nakagawa Y, Kimura T. Clopidogrel Monotherapy After 1-Month DAPT in Patients With High Bleeding Risk or Complex PCI. JACC Asia 2023; 3:31-46. [PMID: 36873770 PMCID: PMC9982293 DOI: 10.1016/j.jacasi.2022.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/29/2022] [Accepted: 09/15/2022] [Indexed: 01/12/2023]
Abstract
Background High bleeding risk (HBR) and complex percutaneous coronary intervention (PCI) are major determinants for dual antiplatelet therapy (DAPT) duration. Objectives The aim of this study was to evaluate the effects of HBR and complex PCI on short vs standard DAPT. Methods Subgroup analyses were conducted on the basis of Academic Research Consortium-defined HBR and complex PCI in the STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy After Verulam's-Eluting Cobalt-Chromium Stent-2) Total Cohort, which randomly compared clopidogrel monotherapy after 1-month DAPT with 12-month DAPT with aspirin and clopidogrel after PCI. The primary endpoint was the composite of cardiovascular (cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) or bleeding (Thrombolysis In Myocardial Infarction [TIMI] major or minor) endpoints at 1 year. Results Regardless of HBR (n = 1,893 [31.6%]) and complex PCI (n = 999 [16.7%]), the risk of 1-month DAPT relative to 12-month DAPT was not significant for the primary endpoint (HBR, 5.01% vs 5.14%; non-HBR, 1.90% vs 2.02%; P interaction = 0.95) (complex PCI, 3.15% vs 4.07%; noncomplex PCI, 2.78% vs 2.82%; P interaction = 0.48) and for the cardiovascular endpoint (HBR, 4.35% vs 3.52%; and non-HBR, 1.56% vs 1.22%; P interaction = 0.90) (complex PCI, 2.53% vs 2.52%; noncomplex PCI, 2.38% vs 1.86%; P interaction = 0.53), while it was lower for the bleeding endpoint (HBR, 0.66% vs 2.27%; non-HBR, 0.43% vs 0.85%; P interaction = 0.36) (complex PCI, 0.63% vs 1.75%; noncomplex PCI, 0.48% vs 1.22%; P interaction = 0.90). The absolute difference in the bleeding between 1- and 12-month DAPT was numerically greater in patients with HBR than in those without HBR (-1.61% vs -0.42%). Conclusions The effects of 1-month DAPT relative to 12-month DAPT were consistent regardless of HBR and complex PCI. The absolute benefit of 1-month DAPT over 12-month DAPT in reducing major bleeding was numerically greater in patients with HBR than in those without HBR. Complex PCI might not be an appropriate determinant for DAPT durations after PCI. (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 [STOPDAPT-2], NCT02619760; Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS [STOPDAPT-2 ACS], NCT03462498).
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Affiliation(s)
- Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kyohei Yamaji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | - Hiroki Watanabe
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Ruka Yoshida
- Department of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Hiroki Sakamoto
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yoshiki Hata
- Department of Cardiology, Minamino Cardiovascular Hospital, Hachioji, Japan
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Hideo Tokuyama
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan
| | - Masahiro Yagi
- Department of Cardiology, Sendai Cardiovascular Center, Sendai, Japan
| | - Hiroshi Suzuki
- Department of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Kohei Wakabayashi
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Nobuhiro Suematsu
- Division of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Tsukasa Inada
- Division of Cardiology, Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | | | - Hideki Okayama
- Department of Cardiology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kazuya Kawai
- Department of Cardiology, Chikamori Hospital, Kochi, Japan
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University Hospital, Isehara, Japan
| | - Yoshihiro Morino
- Department of Cardiology, Iwate Medical University Hospital, Morioka, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Kwon O, Park DW. Antithrombotic Therapy After Acute Coronary Syndromes or Percutaneous Coronary Interventions in East Asian Populations. JACC Asia 2022; 2:1-18. [PMID: 36340250 PMCID: PMC9627845 DOI: 10.1016/j.jacasi.2021.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/13/2021] [Accepted: 12/03/2021] [Indexed: 05/01/2023]
Abstract
Because guidelines and recommendations in response to multiple randomized clinical trials (RCTs) of new therapies undergo rapid changes, antithrombotic therapies for patients after acute coronary syndrome, or percutaneous coronary intervention, are becoming more complex in daily clinical practice. The proportion of Asian populations enrolled in landmark RCTs is substantially low, which limits the direct application of trial findings into clinical practice in Asian countries. Moreover, compared with Caucasian patients, East Asian patients are considered to have a different ischemia/bleeding propensity in response to antithrombotic therapy, known as the "East Asian paradox" (ie, more bleeding events but fewer thromboembolic events). Coincident with consecutive RCTs in Western populations to optimize antithrombotic strategies, several such studies have now been conducted in East Asian cohorts. Herein, we provide a comprehensive summary of the key RCTs in this regard and propose future directions and perspectives for optimal antithrombotic therapies in East Asian patients.
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Key Words
- ACS, acute coronary syndrome
- BARC, Bleeding Academic Research Consortium
- CAD, coronary artery disease
- CHIP, complex higher-risk and indicated procedure/patients
- DAPT, dual antiplatelet therapy
- DES, drug-eluting stent
- DOAC, direct oral anticoagulant
- HBR, high bleeding risk
- MI, myocardial infarction
- OAC, oral anticoagulation
- PCI, percutaneous coronary intervention
- PRU, P2Y12 reaction unit
- RCT, randomized controlled trial
- acute coronary syndrome
- antiplatelets
- antithrombotic therapy
- percutaneous coronary intervention
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Affiliation(s)
- Osung Kwon
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Eunpyeong St Mary's Hospital, Seoul, South Korea
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Duk-Woo Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- Address for correspondence: Dr Duk-Woo Park, Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea.
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