February 1, 2019Journal of the American College of Cardiology
Dual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary Stenting
Key result
Long-term DAPT reduces ischemic events ~4% after complex PCI in non-HBR patients but increases HBR bleeding.
- ARD -3.86%
- 95% CI -7.71 to +0.06
- n=14,963
Why the study?
When concomitant high bleeding risk is present alongside complex PCI, it is unclear whether short- or long-term DAPT should be prioritized.
Study Design
Type
Meta-Analysis (n=14,963)
Randomization
Randomly allocated
Multicenter
Yes
PICO
P
Population
Coronary stenting (PCI) (n=14,963)
I
Intervention / Comparator
Long-term dual antiplatelet therapy (DAPT) vs Short-term DAPT
O
Primary Outcome
Ischemic events — ARD -3.86% (-7.71 to +0.06)
Main Result
Effect estimate: ARD -3.86% (95% CI -7.71 to +0.06)
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We have a huge number of DAPT studies, and the messages given are not always consistent. First, it is difficult for the clinicians to know about all these studies. Second, even if you want to put the energy into reading all of them, you may be more confused than before. The reason why is because DAPT duration depends on patient characteristics.”
“Our patients are faced with a conundrum of how to balance the higher bleeding risk of DAPT that comes with the protection against ischemic events. That is one of the biggest areas of concern. We still do not know the best possible approach, because it is different for every patient.”
Implication
Supports bleeding risk-guided DAPT personalization after complex PCI; leaves open net benefit pending dedicated randomized trials.
Abstract
BACKGROUND: Complex percutaneous coronary intervention (PCI) is associated with higher ischemic risk, which can be mitigated by long-term dual antiplatelet therapy (DAPT). However, concomitant high bleeding risk (HBR) may be present, making it unclear whether short- or long-term DAPT should be prioritized. OBJECTIVES: This study investigated the effects of ischemic (by PCI complexity) and bleeding (by PRECISE-DAPT [PREdicting bleeding Complications in patients undergoing stent Implantation and SubsequEnt Dual AntiPlatelet Therapy] score) risks on clinical outcomes and on the impact of DAPT duration after coronary stenting. METHODS: Complex PCI was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Ischemic and bleeding outcomes in high (≥25) or non-high (<25) PRECISE-DAPT strata were evaluated based on randomly allocated duration of DAPT. RESULTS: Among 14,963 patients from 8 randomized trials, 3,118 underwent complex PCI and experienced a higher rate of ischemic, but not bleeding, events. Long-term DAPT in non-HBR patients reduced ischemic events in both complex (absolute risk difference: -3.86%; 95% confidence interval: -7.71 to +0.06) and noncomplex PCI strata (absolute risk difference: -1.14%; 95% confidence interval: -2.26 to -0.02), but not among HBR patients, regardless of complex PCI features. The bleeding risk according to the Thrombolysis In Myocardial Infarction scale was increased by long-term DAPT only in HBR patients, regardless of PCI complexity. CONCLUSIONS: Patients who underwent complex PCI had a higher risk of ischemic events, but benefitted from long-term DAPT only if HBR features were not present. These data suggested that when concordant, bleeding, more than ischemic risk, should inform decision-making on the duration of DAPT.
Discussion
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Cite This Study
Costa et al. (2019) conducted a meta-analysis in Coronary stenting (PCI) (n=14,963). Long-term dual antiplatelet therapy (DAPT) vs. Short-term DAPT was evaluated on Ischemic events (ARD -3.86%, 95% CI -7.71 to +0.06). Long-term DAPT reduced ischemic events in non-high bleeding risk patients after complex PCI (ARD -3.86%; 95% CI -7.71 to +0.06), but increased bleeding in high bleeding risk patients.