DAPT Score Utility for Risk Prediction in Patients With or Without Previous Myocardial Infarction
Key result
Continued thienopyridine reduces MI or stent thrombosis ~55% vs placebo for DAPT scores ≥2.
- P<0.001
Why the study?
The study sought to determine whether the DAPT score decision tool aids prescription of dual antiplatelet therapy duration in patients with or without prior myocardial infarction treated with coronary stents.
Key Points
- To determine whether the DAPT score decision tool helps guide dual antiplatelet therapy duration in patients with or without previous myocardial infarction after coronary stenting.
- Analysis of randomized trial data (NCT00977938) evaluating continued thienopyridine and aspirin versus placebo and aspirin between 12 and 30 months after coronary stent placement.
- Patients were stratified by history of myocardial infarction (MI) before the index procedure and evaluated according to DAPT score (<2 vs ≥2) for ischemic and bleeding outcomes.
- Continued thienopyridine reduced late MI in patients with prior MI (HR: 0.46, p<0.001) and without prior MI (HR: 0.60, p=0.003), but increased bleeding (HR: 1.86, p=0.01; HR: 1.58, p=0.01, respectively).
- For patients with DAPT score ≥2, extended thienopyridine significantly lowered MI or stent thrombosis compared with placebo in both prior MI (2.7% vs. 6.0%, p<0.001) and no prior MI (2.6% vs. 5.2%, p=0.002) cohorts without excess bleeding.
Study Design
Type
RCT
Blinding
placebo-controlled
Randomization
randomized
PICO
P
Population
Patients treated with coronary stents, with or without prior myocardial infarction, randomized to continued thienopyridine and aspirin versus placebo and aspirin for 12 to 30 months.
I
Intervention / Comparator
Continued thienopyridine and aspirin vs Placebo and aspirin
O
Primary Outcome
MI and/or stent thrombosis in patients with DAPT score ≥2 and any MI history, p=<0.001
Main Result
Absolute Event Rate: 2.7% vs 6%
p-value: p=<0.001
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Dual antiplatelet therapy is standard for patients following coronary stent procedures, but we haven't had good tools to help us determine how long we should be treating individual patients.”
“The DAPT Score was developed to help with this challenging decision, in an effort to help guide and personalize treatment for those patients who are most likely to be helped by continuing the medication and avoid it in those who might be more likely to have serious bleeding. Similar methods could be used in the future to take randomized trial results and tailor them better to individual patients.”
“The DAPT score may help clinicians decide who should and who should not be treated with extended DAPT.”
Implication
Randomized trial demonstrates the DAPT score predicts ischemic and bleeding risks after coronary stenting regardless of prior myocardial infarction, indicating improved guidance for therapy duration.
Abstract
BACKGROUND: The DAPT (Dual Antiplatelet Therapy) study enrolled patients after coronary stenting. Patients randomized to continued thienopyridine and aspirin after 12 months had lower ischemic risk but higher bleeding risk than those treated with placebo and aspirin. OBJECTIVES: This study sought to determine whether a decision tool (DAPT score) aids prescription of dual antiplatelet therapy duration in patients with or without prior myocardial infarction (MI) treated with coronary stents. METHODS: Patients were categorized according to any history of MI before the index procedure or no history of MI. Risk differences during the randomized treatment period (12 to 30 months) for ischemic (MI and/or stent thrombosis) and bleeding (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries moderate/severe) events were compared according to DAPT score. RESULTS: Rates of MI were 3.8% versus 2.4% (p = 0.01) for patients with any MI versus no MI. Continued thienopyridine reduced late MI compared with placebo regardless of MI history (hazard ratio [HR] for any MI: 0.46; p < 0.001; HR for no MI: 0.60; p = 0.003) and increased bleeding (HR: 1.86, p = 0.01 any MI; HR: 1.58, p = 0.01 no MI). DAPT scores ≥2 were associated with reductions in MI/stent thrombosis with continued thienopyridine compared with placebo (2.7% vs. 6.0%, p < 0.001 any MI; 2.6% vs. 5.2%, p = 0.002 no MI), with comparable bleeding rates. Among patients with DAPT scores <2 in both groups, continued thienopyridine was associated with significantly increased bleeding but similar rates of ischemia. CONCLUSIONS: Patients with previous MI have greater risk of late ischemic events than those with no MI history. The DAPT score improves prediction of patient benefit and harm from continued dual antiplatelet therapy beyond assessment of MI history alone. (The Dual Antiplatelet Therapy Study; NCT00977938).
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Cite This Study
Yeh et al. (2016) conducted an RCT in Patients treated with coronary stents with or without prior myocardial infarction. Continued thienopyridine and aspirin vs. Placebo and aspirin was evaluated on MI and/or stent thrombosis in patients with DAPT score ≥2 and any MI history (p=<0.001). Continued thienopyridine reduced MI or stent thrombosis compared with placebo in patients with a DAPT score ≥2, regardless of prior MI history (2.7% vs 6.0%, P<0.001 for prior MI).