P2Y12 inhibitor monotherapy after coronary stenting according to type of P2Y12 inhibitor

Abstract

ObjectiveTo compare P2Y12 inhibitor monotherapy after 3-month dual antiplatelet therapy (DAPT) with 12-month DAPT according to the type of P2Y12 inhibitor in patients undergoing percutaneous coronary intervention (PCI).MethodsThe Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents (SMART-CHOICE) randomised trial compared 3-month DAPT followed by P2Y12 inhibitor monotherapy with 12-month DAPT. In this trial, 2993 patients undergoing successful PCI with drug-eluting stent were enrolled in Korea. As a prespecified analysis, P2Y12 inhibitor monotherapy after 3-month DAPT versus 12-month DAPT were compared among patients receiving clopidogrel and those receiving potent P2Y12 inhibitor (ticagrelor or prasugrel), respectively. The primary endpoint was a composite of all-cause death, myocardial infarction or stroke at 12 months after the index procedure.ResultsAmong 2993 patients (mean age 64 years), 58.2% presented with acute coronary syndrome. Clopidogrel was prescribed in 2312 patients (77.2%) and a potent P2Y12 inhibitor in 681 (22.8%). There were no significant differences in the primary endpoint between the P2Y12 inhibitor monotherapy group and the DAPT group among patients receiving clopidogrel (3.0% vs 3.0%; HR: 1.02; 95% CI 0.64 to 1.65; p=0.93) as well as among patients receiving potent P2Y12 inhibitors (2.4% vs 0.7%; HR: 3.37; 95% CI 0.77 to 14.78; p=0.11; interaction p=0.1). Among patients receiving clopidogrel, P2Y12 inhibitor monotherapy compared with DAPT showed consistent treatment effects across various subgroups for the primary endpoint. Among patients receiving potent P2Y12 inhibitors, the rate of bleeding (Bleeding Academic Research Consortium types 2– 5) was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (1.5% vs 5.0%; HR: 0.33; 95% CI 0.12 to 0.87; p=0.03).ConclusionsCompared with 12-month DAPT, clopidogrel monotherapy after 3-month DAPT showed comparable cardiovascular outcomes in patients undergoing PCI.Trial registration numberNCT02079194.

Initial ticagrelor monotherapy strategy is effective and safe in patient with high bleeding risk after percutaneous coronary intervention: series case reports and literature review

“…Variations in clinical outcomes achieved with regard to diverse con gurations of DAPT and single-drug antiplatelet therapy following a short term of DAPT were observed after PCI. Compared with standard 1-year DAPT, clopidogrel monotherapy after 3 months DAPT attested comparable clinical bene t in patients undergoing PCI (11),but was not seen in clopidogrel monotherapy after 1-2 months DAPT despite reduction in bleeding events (12). However, the same reduction in composite endpoint events was identi ed in STOPDAPT-2 trial with clopidogrel monotherapy followed by one month of DAPT (13).…”

Efficacy and safety of clopidogrel versus ticagrelor for stabilized patients with acute coronary syndromes after percutaneous coronary intervention: results from a real-world registry in China

“…A growing number of clinical studies have attempted the de-escalation strategy of antiplatelet therapy after PCI in patients with ACS, such as low-dose potent P2Y12 inhibitors, reducing the time of antiplatelet drug combination, or guided switching from potent P2Y12 inhibitors to clopidogrel. [22][23][24][25] In this multicenter randomized TALOS-AMI trial, 26 patients with acute myocardial infarction who had received aspirin and ticagrelor in the first month after PCI and had no major ischemic or bleeding events were randomly assigned in a 1:1 ratio to clopidogrel group (clopidogrel plus aspirin) or ticagrelor group (ticagrelor plus aspirin). The results showed that the composite rates of cardiovascular death, myocardial infarction, and stroke did not differ significantly between the 2 groups, and the incidence of major bleeding was lower in the clopidogrel group.…”

P2Y12 Inhibitor Monotherapy after Percutaneous Coronary Intervention

“…Two main post-hoc analyses have been reported. First, the clopidogrel–only cohort (80% of the total sample size), there were no significant differences between clopidogrel monotherapy versus clopidogrel–based DAPT in MACCE (HR, 1.02; 95%CI, [0.64–1.65]; p = 0.100) and BARC 2–5 bleeding (HR, 0.71; 95%CI, [0.42–1.21]; p = 0.150) [ 39 ]. Second, in the platelet reactivity sub-study ( n = 833), 108 (13.0%) patients had HPR who had a significantly increased risk of MACCE compared to those without HPR (8.7% vs. 1.5%; HR, 3.03; 95%CI, [1.06–8.69]; p = 0.038) [ 40 ].…”

“…However, in patients with ACS and clopidogrel monotherapy, the STOPDAPT-2 ACS trial showed reduced bleeding but increased ischemic events [ 43 ]. On the other hand, in CCS, clopidogrel appears to be a safe and effective drug, as shown in the SMART-CHOICE and STOPDAPT-2 trials [ 39 , 42 ]. Moreover, ticagrelor can also be an option in CCS with high ischemic risk as reported in the TWILIGHT trial [ 62 ].…”