Clinical Outcome of First‐ vs Second‐Generation DES According to DAPT Duration: Results of ARCTIC‐Generation

Abstract

There is an apparent benefit with extension of dual antiplatelet therapy (DAPT) beyond 1 year after implantation of drug-eluting stents (DES). Assessment by a Double Randomization of a Conventional Antiplatelet Strategy vs a Monitoring-Guided Strategy for Drug-Eluting Stent Implantation, and of Treatment Interruption vs Continuation One Year After Stenting (ARCTIC)-Generation assessed whether there is a difference of outcome between first-vs second-generation DES and if there is an interaction with DAPT duration in the ARCTIC-Interruption study. ARCTICInterruption randomly allocated 1259 patients 1 year after stent implantation to a strategy of interruption of DAPT (n = 624), in which aspirin antiplatelet treatment only was maintained, or DAPT continuation (n = 635) for 6 to 18 additional months. The primary endpoint was the composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization. A total of 520 and 722 patients received a first-and a second-generation DES, respectively. After a median follow-up of 17 months (interquartile range, 15-18 months) after randomization, the primary endpoint occurred in 32 (6.2%) and 19 (2.6%) patients with first-and second-generation DES, respectively (hazard ratio: 2.31, 95% confidence interval: 1.31-4.07, P = 0.004). This was observed irrespective of the strategy of interruption or continuation of DAPT and timing of study recruitment. Major bleeding events occurred in 4 (0.8%) and 3 patients (0.4%) with first-and second-generation DES, respectively (hazard ratio: 1.79, 95% confidence interval: 0.40-8.02, P = 0.44). Results did not change after multiple adjustments for potential confounding variables. ARCTIC-Generation showed worse clinical outcome with first-vs second-generation DES, a difference that appeared to persist even with prolonged DAPT. 192 Clin. Cardiol. 39, 4, 192-200 (2016) IntroductionAlthough more effective than bare-metal stents in preventing restenosis and ischemia, first-generation drug-eluting stents (DES), such as paclitaxel-eluting stents (PES) and sirolimus-eluting stents (SES), demonstrate increased susceptibility to stent thrombosis (ST). 1 -3 Newer-generation DES with thinner strut stent platforms, biocompatible durable or biodegradable polymers, and limus-based antiproliferative agents have an approximately 50% lower risk of definite or probable ST compared with first-generation DES, particularly during the late phase. 4 -7 This lower risk of ST compared with bare-metal stents, 7,8 together with improved survival compared with medical treatment in stable coronary artery disease (CAD), further support a broad use of this technology. 9 Extended-duration dual antiplatelet therapy (DAPT) prevents atherothrombotic events in patients with symptomatic vascular disease, 10,11 with a significant increased risk of major bleeding and a neutral effect on cardiovascular and noncardiovascular mortality. 12 Duration of DAPT after coronary stenting remains a matter of debate. The susceptibility of first-generation DES to ST, du...

Determinants and Clinical Outcomes of Extended Dual Antiplatelet Therapy over 3 Years after Drug-Eluting Stent Implantation: A Retrospective Analysis

“…A previous study (ARTIC-Generation; Clinical Outcome of First- vs. Second-Generation DES According to DAPT Duration) also indicated worse clinical outcomes with first-generation DESs compared to second-generation DESs, a difference that appeared to persist even with prolonged DAPT (6.2% vs. 2.6%; HR, 2.31; 95% CI, 1.31–4.07; p =0.004). 24 In the current study, extended DAPT use led to a significant reduction in MACCE in patients who were treated with first-generation DESs. Based on the results of this study and other studies, extended DAPT could be carefully considered for patients treated with first-generation DESs.…”

Is the duration of dual antiplatelet therapy (DAPT) excessive in post-angioplasty in chronic coronary syndrome? Data from the France-PCI registry (2014–2019)

“…The recommendations are based on studies confirming the progress observed with the latest generation of DES and the substantial decrease in stent thrombosis rate (2,5). The recommendations published by the ESC in 2017 which proposed to shorten the duration of DAPT post PCI for CCS to 6 months (3), had no impact on the French practices observed in 2018-2019.…”

“…Dual antiplatelet therapy (DAPT) is essential after coronary angioplasty to reduce thrombotic complications (mostly stent thrombosis). Advances in devices and techniques have increased the safety of coronary angioplasty by reducing those complications, with the development of the latest generations of drug eluting stent (DES) in particular (1,2). These technological improvements have allowed a reduction in DAPT duration.…”

Current trends in optimal medical therapy after PCI and its influence on clinical outcomes in China

“…Coronary heart disease (CHD) remains the most significant cause of mortality and a substantial contributor to reduced quality of life worldwide [1,2]. Along with improved stent design, procedural techniques, and effective pharmacological treatments, revascularization therapy has become an essential part of the treatment of CHD [3,4]. Nonetheless, cardiovascular and non-cardiovascular death and other ischemic events driven by atherosclerosis after percutaneous coronary intervention (PCI) remain concerning [5].…”