Much of the speculation around the way of individualizing dual antiplatelet therapy (DAPT) duration after coronary angioplasty has focused on clinical parameters (e. g., diabetes), but a new study published by the Journal of the American College of Cardiology (JACC) and presented at the last European Society of Cardiology (ESC) Congress warns about anatomical factors as event predictors that might help determine dual antiplatelet therapy duration.
In early 2016, the American College of Cardiology (ACC) and the American Heart Association (AHA) published an update on guidelines focused on DAPT duration based on results from the DAPT Study and PEGASUS TIMI 54. These guidelines basically shortened the length of dual antiplatelet therapy from 12 months to 6 months for most patients, while warning about the importance of clinical judgment:
- To extend treatment for over a year in patients with a higher risk of ischemic events.
- To shorten treatment to less than 6 months in patients with a higher risk of bleeding.
Additionally, the DAPT Score was introduced. This tool takes into account patient age, diabetes status, smoking habits, angioplasty history, myocardial infarction history, heart failure, primary angioplasty, vein-graft angioplasty, and stent diameter, in order to single out patients who should undergo extended DAPT.
The criteria for selecting patients for short (3 to 6 months) or extended (at least a year) treatment used in this study are completely different from those applied so far.
In that sense, 9577 patients were stratified by whether they had undergone complex or simple angioplasty. This was assessed taking into account the following:
- Whether 3 vessels were treated.
- Whether at least 3 stents were implanted.
- Whether at least 3 lesions were treated.
- Whether there was a bifurcation lesion with 2 stents implanted.
- Whether total stent length was >60 mm or there was chronic total occlusion.
Overall, combined events in patients who underwent more complex procedures almost doubled the number of events in patients with simpler procedures, which was fairly obvious.
Novelty resided in the fact that patients who underwent complex angioplasty and received extended dual antiplatelet therapy presented a significant reduction in the number of events compared to patients with short dual antiplatelet therapy (hazard ratio [HR]: 0.56; 95% confidence interval [CI]: 0.35-0.89), while, in patients who underwent simple angioplasty, treatment duration showed no significant differences (HR: 1.01; 95% CI: 0.75-1.35; interaction p = 0.01).
The more complex the procedure, the higher the benefit of extending DAPT duration—as well as the risk of bleeding. Bleeding was not specifically related to procedural complexity.
Conclusion
Alongside other well-established clinical risk factors, procedural complexity is an important parameter that should be taken into account when deciding dual antiplatelet therapy duration.
Original title: Efficacy and safety of dual antiplatelet therapy after complex PCI.
Reference: Giustino G et al. J Am Coll Cardiol. 2016;Epub ahead of print.
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