Why the study?
Recent emphasis on shorter DAPT regimens after PCI may fail to account for the substantial residual risk of recurrent atherothrombotic events in ACS patients.
Does extended-term (>12-month) DAPT reduce major adverse cardiac and cerebrovascular events in high-risk TWILIGHT-like patients undergoing PCI for ACS who are event-free at 12 months?
Cohort (n=4,875)
Does extended-term (>12-month) DAPT reduce major adverse cardiac and cerebrovascular events in high-risk TWILIGHT-like patients undergoing PCI for ACS who are event-free at 12 months?
In high-risk ACS patients who are event-free at 12 months post-PCI, extending DAPT beyond 12 months significantly reduces ischemic events without a concomitant increase in clinically meaningful bleeding.
OBJECTIVES: To determine the association of extended-term (>12-month) versus short-term dual antiplatelet therapy (DAPT) with ischemic and hemorrhagic events in high-risk "TWILIGHT-like" patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) in clinical practice. BACKGROUND: Recent emphasis on shorter DAPT regimen after PCI irrespective of indication for PCI may fail to account for the substantial residual risk of recurrent atherothrombotic events in ACS patients. METHODS: All consecutive patients fulfilling the "TWILIGHT-like" criteria undergoing PCI were identified from the prospective Fuwai PCI Registry. High-risk patients (n = 8,358) were defined by at least one clinical and one angiographic feature based on TWILIGHT trial selection criteria. The primary ischemic endpoint was major adverse cardiac and cerebrovascular events at 30 months, composed of all-cause mortality, myocardial infarction, or stroke while BARC type 2, 3, or 5 bleeding was key secondary outcome. RESULTS: Of 4,875 high-risk ACS patients who remained event-free at 12 months after PCI, DAPT>12-month compared with shorter DAPT reduced the primary ischemic endpoint by 63% (1.5 vs. 3.8%; HRadj: 0.374, 95% CI: 0.256-0.548; HRmatched: 0.361, 95% CI: 0.221-0.590). The HR for cardiovascular death was 0.049 (0.007-0.362) and that for MI 0.45 (0.153-1.320) and definite/probable stent thrombosis 0.296 (0.080-1.095) in propensity-matched analyses. Rates of BARC type 2, 3, or 5 bleeding (0.9 vs. 1.3%; HRadj: 0.668 [0.379-1.178]; HRmatched: 0.721 [0.369-1.410]) did not differ significantly between two groups. CONCLUSIONS: Among high-risk ACS patients undergoing PCI, long-term DAPT, compared with shorter DAPT, reduced ischemic events without a concomitant increase in clinically meaning bleeding events, suggesting that prolonged DAPT can be considered in ACS patients who present with a particularly higher risk for thrombotic complications without excessive risk of bleeding.
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Wang et al. (2021) conducted a cohort in Acute coronary syndrome (n=4,875). Extended-term (>12-month) dual antiplatelet therapy (DAPT) vs. Shorter DAPT (≤12 months) was evaluated on Major adverse cardiac and cerebrovascular events at 30 months, composed of all-cause mortality, myocardial infarction, or stroke (HR 0.374, 95% CI 0.256-0.548).
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