This article is more than 5 years old. Information may no longer be current.
Long-term DAPT after PCI fails to benefit patients at high bleeding risk
Long-term dual antiplatelet therapy after PCI was not beneficial in patients at high bleeding risk, regardless of the complexity of their PCI, according to new data from the PRECISE-DAPT study.
The researchers analyzed the effects of ischemic and bleeding risks on outcomes after PCI with stenting and on the effect of DAPT duration.
Francesco Costa, MD, PhD, from the department of clinical and experimental medicine, Policlinico “G. Martino,” University of Messina, Italy, and colleagues evaluated 14,963 patients from eight randomized trials.
Patients were stratified by whether they had complex PCI, defined as any of at least three stents implanted, at least three lesions treated, bifurcation stenting and/or total stent length greater than 60 mm and/or chronic total occlusion; and by whether they were at high bleeding risk, defined as a PRECISE-DAPT score of 25 or more.
Among the cohort, 3,118 patients had complex PCI and had more ischemic events and similar bleeding events compared with those who had noncomplex PCI, according to the researchers.
DAPT outcomes vary
Among patients without high bleeding risk, long-term DAPT, defined as 12 months or more, was associated with reduced ischemic events, both in patients with complex PCI (absolute risk difference, –3.86%; 95% CI, –7.71 to 0.06) and noncomplex PCI (absolute risk difference, –1.14%; 95% CI, –2.26 to –0.02), Costa and colleagues wrote.
However, in patients with high bleeding risk, long-term DAPT did not reduce ischemic events in complex PCI (absolute risk difference, 1.3%; 95% CI, –6.99 to 9.57) or noncomplex PCI (absolute risk difference, 1.45%; 95% CI, –1.84 to 4.72), they found.
In patients with high bleeding risk, long-term DAPT was associated with a significantly higher rate of TIMI major or minor bleeding events in the noncomplex PCI group (absolute risk difference, 2.61%; 95% CI, 0.89-4.31) and a trend toward more bleeding events in the complex PCI group (absolute risk difference, 3.04%; 95% CI, –2.97 to 8.82), the researchers wrote.
Among patients without high bleeding risk, DAPT duration did not affect bleeding events in the complex or noncomplex PCI groups, Costa and colleagues wrote.
“Patients who undergo complex PCI are at further increased risk of ischemic events,” they wrote. “However, such patients do not appear to derive any additional benefit from a long course of DAPT if [high bleeding risk] features (according to the PRECISE-DAPT score) are also present, which ultimately presents an unfavorable net clinical outcome.”
Major signal
In a related editorial, Denis Angoulvant, MD, PhD, from the intensive cardiac care unit and cardiology department, Centre Hospitalier Regional Universitaire de Tours & Tours University, Loire Valley Cardiovascular Collaboration in France, and colleagues wrote that the study is “a major signal for interventional cardiologists willing to individualize post-PCI DAPT duration.”
“A discharge letter recommending the individual optimal DAPT duration based on the hemorrhagic risk evaluation may be beneficial to reduce both ischemic and bleeding risks,” they wrote. – by Erik Swain
Disclosures: Angoulvant reports he has been a consultant and/or speaker for Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, Merck Sharp & Dohme, Novartis, Pfizer, Sanofi and Servier. Costa and the other editorial authors report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.