Early discontinuation of DAPT after PCI increases long-term risk for adverse events
Long-term risk for coronary revascularization, MI and death persisted up to 5 years after premature discontinuation of dual antiplatelet therapy among patients who underwent PCI, researchers reported.
“Other observational studies reported higher short-term risks of death and ischemic events in the first 1 to 2 years after PCI among patients who discontinued DAPT prematurely,” Scott Kinlay, MBBS, PhD, cardiologist at the Veterans Affairs Boston Healthcare System and Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School, and colleagues wrote. “Our study shows that these risks persist, so that even in patients who were free of adverse events in the first year, premature discontinuation of DAPT continued to have a high late risk of death and ischemic events over an average 5 years after PCI.”
For this analysis published in the Journal of the American Heart Association, researchers evaluated whether premature discontinuation of DAPT after PCI was associated with risk at about 5 years. This study included all patients who underwent PCI with first- or second-generation drug-eluting stents in the VA health care system who were free from major ischemic or bleeding events at 12 months.
A total of 8,583 patients underwent PCI with a first-generation DES and 14,239 underwent PCI with a second-generation DES. Premature DAPT discontinuation (1 to 9 months) was compared with 9 to 12 months or extended duration (> 12 months).
Researchers reported that premature discontinuation of DAPT was more likely in Black patients (OR = 1.54; 95% CI, 1.4-1.68), patients with elevated frailty (OR = 1.04; 95% CI, 1.03-1.05) and patients with higher LDL levels (OR = 1.007; 95% CI, 1.006-1.008) and less likely in patients taking statins (OR = 0.87; 95% CI, 0.8-0.95).
DAPT duration was similar for patients who underwent PCI with a second-generation DES (median, 12.5 months) compared with first-generation DES (median, 12.4 months).
Among patients who underwent PCI with second-generation DES, premature discontinuation of DAPT was associated with elevated risk for death (HR = 1.35; 95% CI, 1.185-1.56; P < .0001), MI (HR = 1.46; 95% CI, 1.22-1.74; P < .0001) and coronary revascularization (HR = 1.24; 95% CI, 1.08-1.41; P = .002) compared with 9 to 12 months or extended duration DAPT.
Findings were similar for patients who underwent PCI with a first-generation stent, with discontinuation of DAPT being associated with elevated risk for death (HR = 1.3; 95% CI, 1.13-1.49; P = .0002), MI (HR = 1.28; 95% CI, 1.08-1.53; P = .005) and coronary revascularization (HR = 1.28; 95% CI, 1.12-1.47; P = .0003) compared with 9 to 12 months or extended duration DAPT.
According to the study, models that combined both DES types identified no interactions between DES type and the risk for poorer ischemic outcomes with premature discontinuation of DAPT.
“The implication of our study is that patients who prematurely discontinue DAPT are a high-risk group many years after their PCI,” the researchers wrote. “This increased risk likely relates to comorbidities that increase frailty, bleeding risk, and other social factors, which may warrant more intensive follow-up after PCI to prevent long-term adverse events.”
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