Determinants and Clinical Outcomes of Extended Dual Antiplatelet Therapy over 3 Years after Drug-Eluting Stent Implantation: A Retrospective Analysis

Oh‐Hyun Lee; Byeong‐Keuk Kim; Sung‐Jin Hong; Seunghwan Kim; Chul‐Min Ahn; Dong‐Ho Shin; Jung‐Sun Kim; Tae Soo Kang; Young‐Guk Ko; Donghoon Choi; Myeong‐Ki Hong; Yangsoo Jang

doi:10.3349/ymj.2020.61.7.597

January 1, 2020Yonsei Medical JournalOpen Access

Determinants and Clinical Outcomes of Extended Dual Antiplatelet Therapy over 3 Years after Drug-Eluting Stent Implantation: A Retrospective Analysis

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Why the study?

Although guidelines recommend DAPT for up to 12 months after DES implantation, extended DAPT is frequently used in real-world practice.

Does extended dual antiplatelet therapy (>3 years) improve clinical outcomes compared to guideline-directed therapy (≤1 year) in patients who underwent DES implantation and were event-free for 3 years?

Structured PICO

Does extended dual antiplatelet therapy (>3 years) improve clinical outcomes compared to guideline-directed therapy (≤1 year) in patients who underwent DES implantation and were event-free for 3 years?

P

Population

2,687 patients who underwent percutaneous coronary intervention (PCI) using drug-eluting stents (DES) and were free from major adverse events for 3 years, mean age 62.8, 66% male, from the Korean Multicenter Angioplasty Team registry.

I

Intervention

Extended dual antiplatelet therapy (aspirin and clopidogrel) for more than 3 years after DES implantation.

C

Comparator

Guideline-directed dual antiplatelet therapy (aspirin and clopidogrel) for up to 12 months after DES implantation, followed by single antiplatelet therapy.

O

Outcome

1) Major clinical, angiographic, and procedural determinants for extended-DAPT use; 2) Occurrence of major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of all-cause death, myocardial infarction, stent thrombosis, and stroke.composite

In patients who are event-free 3 years post-DES implantation, extending DAPT beyond 3 years does not significantly reduce MACCE compared to guideline-directed DAPT (≤1 year), though it may benefit those with first-generation DES.

Limitations

Retrospective analysis of registry data
Included only patients who did not experience a major event during 3 years after PCI and were compliant with the designated therapy (survivor/selection bias)

Implication

Extended DAPT should not yet alter practice in event-free post-DES patients; leaves open need for randomized confirmation.

Abstract

Purpose: Although current guidelines recommend the administration of dual antiplatelet therapy (DAPT) for up to 12 months after the implantation of a drug-eluting stent (DES), extended DAPT is frequently used in real-world practice. Materials and Methods: From the Korean Multicenter Angioplasty Team registry, we identified a total of 1414 patients who used DAPT for >3 years after DES implantation (extended-DAPT group) and conducted a landmark analysis at 36 months after the index procedure. We evaluated the determinants for and long-term outcomes of extended DAPT and compared the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of all-cause death, myocardial infarction, stent thrombosis, and stroke, between the extended-DAPT group and the guideline-DAPT group [DAPT <1 year after DES implantation (n=1273)]. Results: Multivariate analysis indicated the occurrence of acute coronary syndrome as the most significant clinical determinant of the use of extended DAPT. Bifurcation, stent diameter 3.0 mm, total stented length 28 mm, and use of first-generation DESs were also significant angiographic and procedural determinants. MACCE rates were similar between the extended-DAPT group and the guideline-DAPT group in crude analysis [hazard ratio (HR), 1.08; 95% confidence interval (CI), 0.69-1.68; p=0.739] and after propensity matching (HR, 1.22; 95% CI, 0.72-2.07; p=0.453). Major bleeding rates were comparable between the two groups.