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CV risk not increased with DAPT cessation in elderly patients
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NEW ORLEANS — Cessation of dual antiplatelet therapy after PCI is more frequent among elderly patients, as compared with younger patients, but their outcomes appear to be no worse after stopping treatment, according to an analysis of the PARIS registry presented at the American College of Cardiology Scientific Session.
“One important finding from this study was the fact that there is major variation in DAPT adherence according to patient age. We found that the older the patients were, the more likely they were to have their DAPT stopped, especially if they were older than 75 years. However, the outcomes were no different for this age group,” Cardiology Today’s Intervention Associate Medical Editor Roxana Mehran, MD, FACC, FAHA, FESC, professor of medicine at Icahn School of Medicine at Mount Sinai, said in an interview.
“In other words, there was no association between major CV outcomes and cessation of DAPT in the elderly, which was not the case for younger patients.”
In the prospective, international, multicenter, observational PARIS registry, the researchers identified three modes of cessation: discontinuation, interruption or disruption. Discontinuation was defined as physician-directed and recommended withdrawal from the antiplatelet agent; interruption was defined as temporary cessation due to surgery and continuation of DAPT treatment within 14 days; and disruption was defined as physician-recommended cessation due to bleeding or patient noncompliance.
Outcomes included bleeding, MACE — defined as a composite of cardiac death, definite or probable stent thrombosis, spontaneous MI or clinically indicated target lesion revascularization — and a secondary restrictive definition of MACE that excluded TLR.
Trends in DAPT cessation
Of the 5,018 patients included in the study, 24% were aged 55 years or younger, 57% were aged 56 to 74 years and 19% were aged at least 75 years.
The data showed that as age increased, so did the cumulative incidence of discontinuation (P < .0001) and interruption (P = .003) at 2 years. The incidence of disruption was highest among elderly patients, and higher among those aged 56 to 74 years vs. those aged 55 years or younger (18.1% vs. 14.3% vs. 13%; P = .0003).
The most frequent mode of cessation was discontinuation, followed by disruption and interruption. Notably, the frequency of discontinuation increased until age 80 years and decreased thereafter, whereas the frequency of disruption decreased as patients approached age 60 years and then increased from age 60 to 90 years. The frequency of interruption also increased as patients aged but plateaued after age 60 years.
“We make a significant effort in the elderly patient population to discontinue DAPT, which is why it was the most frequent mode of cessation,” Mehran said.
Link between DAPT cessation, adverse outcomes
At 2 years, the overall incidence of death, cardiac death, Bleeding Academic Research Consortium (BARC) major bleeding, TIMI major bleeding and secondary MACE increased as patients aged and was significantly higher in elderly patients. Elderly patients also still had higher rates of death, cardiac death, BARC major bleeding and secondary MACE after adjustment for sex, diabetes, location, stent type and number of stents implanted. However, the incidence of TLR was lower in elderly patients vs. younger patients after adjustment (P = .02).
Results showed that physician-recommended DAPT discontinuation was linked to lower adverse event rates among younger patients and was not associated with an increased risk for MACE among elderly patients (P for trend = .01).
Additionally, physician-recommended discontinuation was not linked to an increased risk for secondary MACE, with no significant trends according to age group. Age also did not affect the risk for either definition of MACE with DAPT interruption.
However, DAPT disruption was associated with an increased risk for MACE and secondary MACE in patients aged 55 years and younger and those aged 56 to 74 years, but CV risk was attenuated in those aged at least 75 years (MACE, P for trend = .03; secondary MACE, P for trend < .0001).
“When you look at age in and of itself, elderly patients have the highest rate of mortality, bleeding and major CV events. However, in looking at cessation patterns and what happens when DAPT is stopped, we didn’t see the important effect that we were seeing in the younger patient population,” Mehran said.
Clinical considerations
These results are interesting, according to Mehran, as the decision-making process regarding DAPT duration in patients is complicated, perhaps even more so in the elderly patient population.
“We’re now realizing that these elderly patients, while they are extremely complex, discontinuation, interruption or disruption of DAPT doesn’t seem to have an important impact on their outcomes. In fact, they seem to do better when their DAPT is stopped, which fits into the notion that bleeding prevails in these patients, and we should be thinking about that in a very serious manner,” she told Cardiology Today’s Intervention.
“This analysis needs further evaluation and we need further observation so we can appropriately determine the risk-benefit ratio in this patient population,” Mehran said.
This study was also published in JACC: Cardiovascular Interventions. – by Melissa Foster
References:
Joyce LC. Abstract 1204-054. Presented at: American College of Cardiology Scientific Session; March 16-18, 2019; New Orleans.
Joyce LC, et al. JACC Cardiovasc Interv. 2019;doi:10.1016/j.jcin.2019.02.033.
Disclosures: The PARIS study was supported by research grants from Bristol-Myers Squibb and Sanofi. Mehran reports she has received research funding from AstraZeneca, Bayer, Beth Israel Deaconess, Bristol-Myers Squibb; she is a consultant to Abbott Laboratories, Abiomed, Boston Scientific, Cardiovascular Systems, Medscape, Siemens Medical Solutions, The Medicines Company, PLx Opco, Regeneron, Roivant Sciences, Spetranetics/Phillips/Volcano Corporation; she is part of the executive committees of Janssen Pharmaceuticals and Osprey Medical; she is part of the advisory board of Bristol-Myers Squibb; she is a DSMB member of Watermark Research Partners; and she has received equity from Claret Medical and Elixir Medical. Joyce reports no relevant financial disclosures.