Comparison of Systematic Ticagrelor-Based Dual Antiplatelet Therapy to Selective Triple Antithrombotic Therapy for Left Ventricle Dysfunction Following Anterior STEMI

Abstract

Antithrombotic management of STEMI patients with apical dysfunction, but without demonstrable thrombus, is controversial. Triple antithrombotic therapy (TATT, defined as the addition of oral anticoagulation to dual antiplatelet therapy, or DAPT) may be associated with increased bleeding, while DAPT alone may not adequately protect against cardio-embolic events. We undertook a dual-center study of anterior STEMI patients treated with primary PCI (pPCI) from 2013 to 2015 and presenting presumed new apical dysfunction. The Centre hospitalier de l’Université de Montréal (CHUM) uses a strategy of selective TATT, whereas the Centre hospitalier universitaire de Sherbrooke (CHUS) has favored ticagrelor-based DAPT for all patients since 2013. The primary composite outcome consisted of death, MI, stroke, revascularization, and BARC 3 to 5 bleeding up to 4-months follow-up. We identified 177 cases (69 CHUM; 108 CHUS). Baseline characteristics were similar and procedural success was high (97%). There was no difference in post-procedure LVEF (39 ± 9% vs 37 ± 9%) or the extent of apical dysfunction. The primary composite outcome occurred in 27% with the selective TATT strategy compared to 19% with ticagrelor-DAPT (p = 0.342). Thus, this retrospective dual-center analysis does not support a strategy of conventional TATT over ticagrelor-based DAPT for patients with apical dysfunction following anterior STEMI treated with pPCI. A pragmatic randomized trial is needed to provide a definitive answer to this clinical conundrum.

Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association

“…103 A study comparing a treatment strategy of ticagrelor-based DAPT at 1 hospital with triple antithrombotic therapy at another hospital in patients treated with primary PCI for anterior STEMI with “apical dysfunction” found no difference in a composite end point of ischemic and bleeding events, although only 1 patient in the study had a stroke or TIA. 104 There are overall insufficient high-quality study data to assess whether DAPT alone has any protective effects for the formation of LV thrombus or whether a more potent P2Y 12 inhibitor such as ticagrelor might be preferable if DAPT alone is used to treat patients at risk of LV thrombus formation.…”

Safety and Efficacy Evaluation of Antithrombotic Therapy with Rivaroxaban and Clopidogrel After PCI in Chinese Patients

“…Studies have also shown that rivaroxaban based antithrombotic regimens can reduce total bleeding events, including events other than the first event in patients with AF who receive antiplatelet therapy after PCI. 24 , 25 Brunetti, ND et al performed a meta-analysis that included patients with NVAF treated with PCI and assessed all bleeding risks 26 : compared with patients receiving the three groups of standard treatment, patients who received rivaroxaban or dabigatran had a significantly lower risk of bleeding. The above results are consistent with the results of our study.…”