The 1-month outcomes of dual antiplatelet therapy (DAPT) followed by clopidogrel monotherapy were comparable to 12-month DAPT in patients with both simple and complex PCI. There was no significant interaction between DAPT period and procedure difficulty.
This is a post hoc study of the STOPDAPT-2 that looked at the complex PCI patient subgroup.
It is important given the uncertain results of clopidogrel monotherapy after a very short DAPT period (1 month), especially in complex PCI.
The general STOPDAPT-2 randomized patients to 1-month DAPT followed by clopidogrel monotherapy vs. 12-month DAPT in patients undergoing PCI with everolimus eluting stent.
The substudy defined complex PCI as: 3 target vessels, ≥3 target lesions, ≥3 stents implanted, bifurcation with 2 stent technique, stent length > 60 mm, or chronic total occlusion. With the exception of the left main, these are the traditional criteria which define a complex PCI.
Primary end point was a composite of cardiovascular death, MI, definite thrombosis, stroke and bleeding (according to TIMI criteria).
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Of 3.009 patients included in the general study, 509 met the criteria for complex PCI (16.9%). There was no significant interaction between PCI complexity and 1-month DAPT vs 12-month DAPT in primary end points (complex PCI: 1.67% vs 5.32%, HR 0.30, p=0.04, and simple PCI: 2.5% vs 3.35%, HR 0.75, p=0.23 and for the interaction=0.14).
Accumulated major bleeding was significatively lower in patients receiving 1-month DAPT. This was true regardless PCI complexity.
Together with the increasing evidence in favor of short DAPT schemes after DES stenting, there is increasing uncertainty over the best monotherapy drug to follow up with. It has been hard to cross data with studies such as the Xience 28 which, unlike the STOPDAPT-2, used aspirin as monotherapy, seeing as it specifically included patients at high risk of bleeding.
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Once contemporary DES reach the “class effect”, will come the time to randomize a very short DAPT scheme followed by aspirin vs. a very short DAPT scheme followed by a P2Y12 inhibitor.
Conclusion
Clopidogrel monotherapy after 1-month DAPT is comparable to 12-month DAPT in patients receiving complex PCI.
Original Title: Very Short Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation in Patients Who Underwent Complex Percutaneous Coronary Intervention: Insight From the STOPDAPT-2 Trial.
Reference: Ko Yamamoto et al. Circulation: Cardiovascular Interventions. 2021;14:e010384. https://doi.org/10.1161/CIRCINTERVENTIONS.120.010384.
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