A Chinese registry study found there are higher event rates in patients with shorter dual-antiplatelet therapy (DAPT) after PCI procedures. There has been a lot of movement toward using shorter duration DAPT with newer generation drug-eluting stent technologies, but this study reinforces the need longer DAPT in many patients. The findings were presented as a late-breaking trial at SCAI 2021 today.
April 28, 2021 — An analysis of the prospective Chinese Fuwai PCI Registry, confirms long-term, dual-antiplatelet therapy (DAPT) is an optimal treatment option for acute coronary syndrome patients (ACS) following a percutaneous coronary intervention (PCI). The study shows long-term DAPT reduces ischemic events without increasing bleeding or other complications as compared to short-term DAPT treatments.
The study. Establishing the Optimal Duration of DAPT After PCI in High-Risk TWILIGHT-like patients with Acute Coronary Syndrome, was presented today as late-breaking clinical research at the Society for Cardiovascular Angiography and Interventions (SCAI) 2021 Scientific Sessions.
Following ACS, patients have a high risk of ischemic events, which impacts chances of survival.[1,2] Patients are predisposed for blood clots within an artery for years after an ischemic event,[3,4,5] suggesting that the pathobiology of recurrent events post-ACS differs from that of stable coronary artery disease (CAD) patients who have not offered a previous ischemic event. Therefore, ACS patients may be more likely to benefit from long-term secondary prevention strategy, like extended duration DAPT.
DAPT with aspirin and a P2Y12 inhibitor is the cornerstone of management after an ACS. Current practice guidelines recommend treatment of ACS patients include more aggressive risk factor modification and prolonged antiplatelet therapy, as well as DAPT for a minimum of 12 months following an ACS, regardless of whether or not PCI is performed.[7,8] In addition to protecting against stent thrombosis in the culprit lesion, an important objective of long-term DAPT in patients with ACS is the prevention of future coronary ischemic events from nonculprit lesions, as demonstrated in earlier trials.[9,10,11,12] With the improvement of stent device technology, studies evaluating the safety and efficacy of shortening DAPT to less than 12-months in patients with ACS undergoing PCI reported conflicting results.[13,14,15]
The study included 4,875 high-risk “TWILIGHT-like” patients undergoing PCI. The high-risk patients were defined by at least one clinical and one angiographic feature based on TWILIGHT trial selection criteria, with ACS who were event free at 12 months after PCI from the Fuwai PCI Registry. The primary outcome was the composite of all-cause death, MI or stroke at 30 months while the Bleeding Academic Research Consortium (BARC) type 2,3 or 5 bleeding was key secondary outcome. Results showed that slightly more than two-third of ACS patients remained on DAPT beyond 12 months after PCI. Extended DAPT compared with shorter DAPT reduced the composite outcome of all-cause death, MI or stroke by 63%. BARC type 2, 3, or 5 bleeding rates did not differ significantly in patients treated with DAPT longer than 12-months versus those treated with DAPT less than 12-months. The effect of long-term DAPT on primary and key secondary outcome across the proportion of ACS patients with 1-3, 4-5, or 6-9 risk factors showed a consistent manner.
“Our findings suggested that prolonged DAPT in ACS patients who present with a particularly higher risk for thrombotic complications without excessive risk.” said Haoyu Wang, M.D., Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China. “Not only did we see long-term DAPT was associated with a lower risk of a major cardiovascular event without an increase in bleeding events, but it it could be considered an effective strategy to balance the risk for bleeding and ischemia in high-risk patients with ACS. Our results reinforce prolonged DAPT in patients with acute coronary syndrome without excessive risk of bleeding should remain the standard of care.”
Authors call for further analysis on high bleeding risk and ischemia patients and work to publish in additional publications across Asia.
1. Szummer K, Jernberg T, Wallentin L. From Early Pharmacology to Recent Pharmacology Interventions in Acute Coronary Syndromes: JACC State-of-the-Art Review. Journal of the American College of Cardiology 2019;74(12):1618-1636. (In eng). DOI: 10.1016/j.jacc.2019.03.531.
2. Kukreja N, Onuma Y, Garcia-Garcia HM, Daemen J, van Domburg R, Serruys PW. The risk of stent thrombosis in patients with acute coronary syndromes treated with bare-metal and drug-eluting stents. JACC Cardiovascular interventions 2009;2(6):534-41. (In eng). DOI: 10.1016/j.jcin.2009.04.003.
3. Jernberg T, Hasvold P, Henriksson M, Hjelm H, Thuresson M, Janzon M. Cardiovascular risk in post-myocardial infarction patients: nationwide real world data demonstrate the importance of a long-term perspective. European heart journal 2015;36(19):1163-70. (In eng). DOI: 10.1093/eurheartj/ehu505.
4. Alnasser SM, Huang W, Gore JM, et al. Late Consequences of Acute Coronary Syndromes: Global Registry of Acute Coronary Events (GRACE) Follow-up. The American journal of medicine 2015;128(7):766-75. (In eng). DOI: 10.1016/j.amjmed.2014.12.007.
5. Fox KA, Carruthers KF, Dunbar DR, et al. Underestimated and under-recognized: the late consequences of acute coronary syndrome (GRACE UK-Belgian Study). European heart journal 2010;31(22):2755-64. (In eng). DOI: 10.1093/eurheartj/ehq326.
6. Rodriguez F, Harrington RA. Management of Antithrombotic Therapy after Acute Coronary Syndromes. The New England journal of medicine 2021;384(5):452-460. (In eng). DOI: 10.1056/NEJMra1607714.
7. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology 2016;68(10):1082-115. (In eng). DOI: 10.1016/j.jacc.2016.03.513.
8. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). European heart journal 2018;39(3):213-260. (In eng). DOI: 10.1093/eurheartj/ehx419.
9. Yeh RW, Kereiakes DJ, Steg PG, et al. Benefits and Risks of Extended Duration Dual Antiplatelet Therapy After PCI in Patients With and Without Acute Myocardial Infarction. Journal of the American College of Cardiology 2015;65(20):2211-21. (In eng). DOI: 10.1016/j.jacc.2015.03.003.
10. Mehta SR, Yusuf S, Peters RJ, et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 2001;358(9281):527-33. (In eng). DOI: 10.1016/s0140-6736(01)05701-4.
11. Kereiakes DJ, Yeh RW, Massaro JM, et al. DAPT Score Utility for Risk Prediction in Patients With or Without Previous Myocardial Infarction. Journal of the American College of Cardiology 2016;67(21):2492-502. (In eng). DOI: 10.1016/j.jacc.2016.03.485.
12. Furtado RHM, Nicolau JC, Magnani G, et al. Long-term ticagrelor for secondary prevention in patients with prior myocardial infarction and no history of coronary stenting: insights from PEGASUS-TIMI 54. European heart journal 2020;41(17):1625-1632. (In eng). DOI: 10.1093/eurheartj/ehz821.
13. Palmerini T, Della Riva D, Benedetto U, et al. Three, six, or twelve months of dual antiplatelet therapy after DES implantation in patients with or without acute coronary syndromes: an individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients. European heart journal 2017;38(14):1034-1043. (In eng). DOI: 10.1093/eurheartj/ehw627.
14. Hahn JY, Song YB, Oh JH, et al. 6-month versus 12-month or longer dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome (SMART-DATE): a randomised, open-label, non-inferiority trial. Lancet 2018;391(10127):1274-1284. (In eng). DOI: 10.1016/s0140-6736(18)30493-8.
15. Kedhi E, Fabris E, van der Ent M, et al. Six months versus 12 months dual antiplatelet therapy after drug-eluting stent implantation in ST-elevation myocardial infarction (DAPT-STEMI): randomised, multicentre, non-inferiority trial. BMJ 2018;363:k3793. (In eng). DOI: 10.1136/bmj.k3793.