Balancing Bleeding Risk vs. Thrombotic Risk to Define Dual Antiplatelet Therapy Duration

Patients who undergo complex angioplasty are at higher ischemic risk, but only benefit from extended dual antiplatelet therapy if there are no factors for high bleeding risk. These data suggest that the bleeding risk must weigh more than the ischemic risk on the determination of dual antiplatelet therapy duration.

Complex angioplasty is associated with higher ischemic risk, which can be partially mitigated by extending the duration of dual antiplatelet therapy. In any case, there is a bleeding risk and it may be high, so the question regarding which risk should be prioritized is a daily discussion among interventional cardiologists, who see bleeding as a complication for patients and not for them (they only care about thrombosis). In the meantime, clinical cardiologists are caught in the middle. They make the decision, but, sometimes, their scales are not well calibrated.

Complex angioplasty was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation with 2 stents, stent length >60 mm, and/or chronic total occlusions. Risk was considered high when the PRECISE-DAPT score was >25 or when it was not below that. Patients were stratified according to these characteristics and randomized to short- or long-term dual antiplatelet therapy.

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There were 14,963 total patients from 8 randomized trials, among whom 3118 patients underwent complex angioplasty with high ischemic risk, but did not experience bleeding events.

Extending dual antiplatelet therapy in patients with low bleeding risk was beneficial because it reduced ischemic events in both complex (absolute risk difference: -3.86%; 95% confidence interval [CI]: -7.71 to +0.06) and noncomplex angioplasty patients (absolute risk difference: -1.14%; 95% CI: -2.26 to -0.02). However, that did not happen in patients with high bleeding risk, beyond angioplasty complexity.

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The bleeding risk according to the Thrombolysis In Myocardial Infarction (TIMI) scale was increased with extended dual antiplatelet therapy only in patients with high bleeding risk (>25 PRECISE-DAPT score), regardless of angioplasty complexity.

Conclusion

Patients who undergo complex angioplasty can benefit from extended dual antiplatelet therapy only if they present low bleeding risk. At the crossroads, decisions on dual antiplatelet therapy duration should prioritize the bleeding risk over the ischemic risk.

Original title: Dual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary Stenting.

Reference: Francesco Costa et al. J Am Coll Cardiol 2019;73:741-54.

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