New Insights Into Long- Versus Short-Term Dual Antiplatelet Therapy Duration in Patients After Stenting for Left Main Coronary Artery Disease: Findings From a Prospective Observational Study. (18th May 2022)

• Record Type: Journal Article
• Authors: Wang, Hao-Yu; Dou, Ke-Fei; Guan, Changdong; Xie, Lihua; Huang, Yunfei; Zhang, Rui; Yang, Weixian; Wu, Yongjian; Yang, Yuejin; Qiao, Shubin; Gao, Runlin; Xu, Bo
• Is Part Of: Circulation. Volume 15:Number 6(2022)
• Page Start: e011536
• Publication Date: 2022-05-18
• Subjects: bleeding -- dual anti-platelet therapy -- ischemia -- left main coronary artery disease -- percutaneous coronary intervention; Cardiovascular system -- Surgery -- Periodicals; Cardiovascular system -- Diseases -- Treatment -- Periodicals; 616.105
• DOI: 10.1161/CIRCINTERVENTIONS.121.011536
• Languages: English
• ISSNs: 1941-7640

Abstract

Abstract : Background: The appropriate duration of dual antiplatelet therapy (DAPT) and risk-benefit ratio for long-term DAPT in patients with left main (LM) disease undergoing percutaneous coronary intervention remains uncertain. Methods: Four thousand five hundred sixty-one consecutive patients with stenting of LM disease at a single center from January 2004 to December 2016 were enrolled. Decision to discontinue or remain on DAPT after 12 months was left to an individualized decision-making based on treating physicians by weighing the patient's risks of ischemia versus bleeding and considering patient preference. The primary outcome was a composite of death, myocardial infarction, stent thrombosis, or stroke at 3 years. Key safety outcome was 3-year rate of Bleeding Academic Research Consortium 2, 3, or 5 bleeding. Results: Of 3865 patients free of ischemic and bleeding events at 12 months, 1727 (44.7%) remained on DAPT (mostly clopidogrel based [97.7%]) beyond 12 months after LM percutaneous coronary intervention. DAPT>12-month versus ≤12-month DAPT was associated with a significant reduced risk of 3-year primary outcome (2.6% versus 4.6%; adjusted hazard ratio: 0.59 [95% CI, 0.41–0.84]). The same trend was found for other ischemic end points: death (0.9% versus 3.0%; P log-rank <0.001), cardiovascular death (0.5% versus 1.7%; P log-rank =0.001), myocardial infarction (0.8% versus 1.9%; P log-rank =0.005), and stent thrombosis (0.4% versus 1.1%; P log-rank =0.017). The key safety end point was not significantly different between 2 regimens (1.8% versus 1.6%; adjusted hazard ratio: 1.07 [95% CI, 0.65–1.74]). The effect of DAPT>12 month on primary and key safety outcomes was consistent across clinical presentations, high bleeding risk, P2Y12 inhibitor, and LM bifurcation percutaneous coronary intervention approach. Conclusions: In a large cohort of patients free from clinical events during the first year after LM percutaneous coronary intervention and at low apparent future bleeding risk, an individualized patient-tailored approach to longer duration (>12 month) of DAPT with aspirin plus a P2Y12 inhibitor (mostly clopidogrel) improved both composite and individual efficacy outcomes by reducing ischemic risk, without a concomitant increase in clinically relevant bleeding.