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Extended DAPT after PCI reduces ischemic event risk, increases bleeding event risk in PAD
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Extending dual antiplatelet therapy beyond 1 year reduced the risk for ischemic events and increased the risk for bleeding in patients with peripheral artery disease who underwent coronary stenting, according to a subanalysis of the DAPT trial.
Of 11,648 patients who were randomly assigned to 18 months of continued thienopyridine plus aspirin therapy or aspirin therapy alone 12 months after coronary stenting, 649 (5.57%) had PAD. Eric A. Secemsky, MD, MSc, of the division of cardiology at Massachusetts General Hospital, and colleagues assessed MI or stent thrombosis, MACCE (including death, MI or stroke), and bleeding, as measured by the GUSTO classification, at 30 months. All patients who continued on thienopyridine through 30 months were free from ischemic and bleeding events 12 months after coronary stenting.
Compared with patients without PAD, those with PAD had higher rates of MI or stent thrombosis (6.03% vs. 2.92%; P < .001), MACCE (11.65% vs. 4.62%; P < .001) and bleeding (4.86% vs. 1.74%; P < .001) from 12 to 30 months.
Additionally, from 12 to 30 months, continued thienopyridine vs. placebo was associated with consistent reductions in the risk for MI or stent thrombosis in patients with PAD (HR = 0.63; 95% CI, 0.32-1.22) and patients without PAD (HR = 0.53; 95% CI, 0.42-0.66; P for interaction = .631). Continued thienopyridine vs. placebo also had similar treatment effects on MACCE in patients with PAD (HR = 1.06; 95% CI, 0.67-1.67) and patients without PAD (HR = 0.7; 95% CI, 0.59-0.84; P for interaction = .103).
Increased risk for bleeding associated with continued thienopyridine vs. placebo was comparable for patients with PAD (HR = 1.82; 95% CI, 0.87-3.83) and patients without PAD (HR = 1.66; 95% CI, 1.23-2.24; P for interaction = .811).
“Extending DAPT more than 1 year after coronary stenting may be of benefit to select patients with PAD who are at high risk of recurrent ischemia and low risk of bleeding, similar to the general population of stented patients,” the researchers wrote.
In an accompanying editorial comment, Hans-Henning Eckstein, MD, PhD, and Thomas Stadlbauer, MD, both from the Technical University of Munich, noted that researchers cannot yet draw firm conclusions about the benefit of extending DAPT after coronary stenting in patients with PAD.
“Nevertheless, the presented DAPT subgroup analysis is an important contribution to the published reports, because data on this specific population with a high atherosclerotic burden are sparse,” they wrote. “Future trials focusing on drug-based treatment of PAD with and without CHD are warranted. This paper represents a step in this direction.” – by Melissa Foster
Disclosure: Secemsky reports no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures. Eckstein reports receiving research funding grants from Bayer AG. Stadlbauer reports receiving research grants from Bayer AG and speaking for Bristol-Myers Squibb, Daiichi Sankyo and Pfizer.
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