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In patients with elevated lipoprotein(a) concentrations after percutaneous coronary intervention, prolonged dual antiplatelet therapy (>1 year) significantly reduces ischemic cardiovascular events and mortality without increasing clinically relevant bleeding risk. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

December 20, 2021Frontiers in Cardiovascular Medicine11 citationsOpen Access

Benefit and Risk of Prolonged Dual Antiplatelet Therapy After Percutaneous Coronary Intervention With Drug-Eluting Stents in Patients With Elevated Lipoprotein(a) Concentrations

KCKongyong Cui HWHaoyu Wang DYDong Yin

Structured PICO

Does prolonged dual antiplatelet therapy (>1 year) reduce major adverse cardiovascular and cerebrovascular events in CAD patients with elevated lipoprotein(a) levels after PCI with drug-eluting stents?

Population

3,025 coronary artery disease (CAD) patients with elevated lipoprotein(a) levels (>30 mg/dl) who were event-free at 1 year after percutaneous coronary intervention (PCI) with drug-eluting stents (DES). Mean age 58.7 years, 73.8% male. Excluded patients with normal Lp(a), missing data, follow-up ≤1 year, non-DES use, or adverse cardiovascular events within 1-year follow-up.

Intervention

Prolonged dual antiplatelet therapy (DAPT) >1 year (aspirin plus clopidogrel)

Comparator

Dual antiplatelet therapy (DAPT) ≤1 year (aspirin plus clopidogrel)

Outcome

Major adverse cardiovascular and cerebrovascular event (MACCE), defined as a composite of all-cause death, non-fatal myocardial infarction, or stroke at median 2.4 years follow-upcomposite

In patients with elevated lipoprotein(a) after PCI, prolonging DAPT beyond 1 year significantly reduces ischemic events and mortality without increasing clinically relevant bleeding.

Limitations

Single-center, non-randomized study
Limited by unbalanced baseline characteristics and selection bias
Duration of DAPT was not predefined but individualized by physician discretion

Abstract

Background: Lipoprotein(a) is positively related to cardiovascular events in patients with coronary artery disease (CAD). Given that lipoprotein(a) has a prothrombotic effect, prolonged dual antiplatelet therapy (DAPT) might have a beneficial effect on reducing ischemic events in patients with elevated lipoprotein(a) levels after percutaneous coronary intervention (PCI). We performed this study to assess the efficacy and safety of prolonged DAPT (1 year) in this population. Methods: We evaluated a total of 3,025 CAD patients with elevated lipoprotein(a) levels who were event-free at 1 year after PCI from the prospective Fuwai PCI Registry, of which 913 received DAPT ≤ 1 year and 2,112 received DAPT1 year. The primary endpoint was major adverse cardiovascular and cerebrovascular event (MACCE), defined as a composite of all-cause death, myocardial infarction or stroke. Results: After a median follow-up of 2.4 years, patients who received DAPT1 year were associated with lower risks of MACCE compared with DAPT ≤ 1 year (1.6 vs. 3.8%; hazard ratio HR 0.383, 95% confidence interval CI 0.238–0.616), which was primarily driven by the lower all-cause mortality (0.2 vs. 2.3%; HR 0.078, 95% CI 0.027–0.227). In addition, DAPT1 year was also associated with lower risks of cardiac death, and definite/probable stent thrombosis than those who received DAPT ≤ 1 year ( P 0.05). Conversely, no difference was found between the two groups in terms of clinically relevant bleeding. Similar results were observed in multivariate Cox regression analysis and inverse probability of treatment weighting analysis. Conclusions: In patients with elevated lipoprotein(a) concentrations after PCI, prolonged DAPT (1 year) reduced ischemic cardiovascular events, including MACCE, all-cause mortality, cardiac mortality, and definite/probable stent thrombosis, without increase in clinically relevant bleeding risk compared with ≤ 1-year DAPT. Lipoprotein(a) levels might be a new important consideration when deciding the duration of DAPT after PCI.

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