Dual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary Stenting

Costa, Francesco; Klaveren, David van; Feres, Fausto; James, Stefan; Räber, Lorenz; Pilgrim, Thomas; Hong, Myeong‐Ki; Kim, Hyo–Soo; Colombo, Antonio; Steg, Philippe Gabríel; Bhatt, Deepak L.; Stone, Gregg W.; Windecker, Stephan; Steyerberg, Ewout W.; Valgimigli, Marco; Investigators, Precise-Dapt Study

doi:10.1016/j.jacc.2018.11.048

Cited by 227 publications

(159 citation statements)

References 33 publications

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“…Intriguingly, subjects with complex PCI did not experience a significant increased risk of clinically relevant bleeding, as compared with the noncomplex PCI group. In this regard, three analyses from DAPT study, PROMETHEUS study, and a pooled patient-level data from six RCTs showing comparable clinically relevant bleeding risks between complex and noncomplex PCI groups were consistent with our findings [7][8][9]13]. In contrast to these observations, the results of ADAPT-DES registry and Global Leaders trial showed that complex PCI criteria were correlated with a higher incidence of bleeding [10,12].…”

Section: Discussionsupporting

confidence: 88%

“…Given that these high-risk features were established risk factors of thrombotic complications [20][21][22], such patients that were excluded from a patient-level pooled dataset from six RCTs are necessary to be taken into account in a real-world practice. Under this scenario, it is unsurprising that the proportion of patients receiving complex procedures was markedly higher (35.9%) in our study than in two previous pooled patient-level databases from RCTs that ranged from 17.9% to 29.6% [7,12,13]. Furthermore, high-risk features from the Bern PCI Registry were mainly comprised of CKD (47.6%) [11], which has emerged as a common contributor to both types of ischemic and bleeding complications [16,25].…”

Section: Discussionmentioning

confidence: 63%

“…Although procedural complexity emerges as a correlate of ischemic events, controversial results have been reported in many studies evaluating the adverse impact of complex PCI procedures on bleeding events [7][8][9][10][11][12]. For instance, some reports suggested the increased risk of bleeding events in patients with high-risk features for stentrelated ischemic events [10][11][12], whereas others refuted this association [7][8][9]13]. Meanwhile, concomitant high bleeding risk (HBR) may be present, making it challenging for clinical decision-making on the duration and intensity of dual antiplatelet therapy (DAPT) after complex PCI.…”

Section: Introductionmentioning

confidence: 99%

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Percutaneous Coronary Intervention Complexity and Risk of Adverse Events in Relation to High Bleeding Risk Among Patients Receiving Drug-Eluting Stents: Insights From a Large Single-Center Cohort Study

Wang

Dou

2020

Journal of the American College of Cardiology

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Background/Aim. e relation between complex percutaneous coronary intervention (PCI), high bleeding risk (HBR), and adverse events after coronary artery implantation of drug-eluting stents has been incompletely characterized. is study sought to investigate the ischemic and bleeding events after complex PCI including stratification according to HBR estimated by PARIS bleeding risk score. Methods. Between January 2013 and December 2013, 10,167 consecutive patients undergoing PCI were prospectively enrolled in Fuwai PCI Registry. Complex PCI was defined when having at least one of the following characteristics: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, treatment of chronic total occlusion, unprotected left main PCI, in-stent restenosis target lesion, and severely calcified lesion. e primary ischemic endpoint was major adverse cardiovascular events (MACE) (composite of cardiac death, myocardial infarction, definite/ probable stent thrombosis, and target lesion revascularization), and primary bleeding endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding. Results. e median duration of follow-up was 29 months. In adjusted Cox regression analysis, patients having complex PCI procedures experienced higher risks of MACE (hazard ratio (HR): 1.63, 95% confidence interval (CI): 1.38-1.92; P < 0.001), compared with noncomplex PCI. In contrast, the risk of clinically relevant bleeding was statistically similar between the 2 groups (HR: 0.86 [0.66-1.11]; P � 0.238). ere was no statistical interaction between HBR (PARIS bleeding score ≥8 or <8) and complex PCI in regard to MACE (adjusted P interaction � 0.388) and clinically relevant bleeding (adjusted P interaction � 0.279). Conclusions. Patients who had undergone complex PCI resulted in substantially more ischemic events, without an increase in clinically relevant bleeding risk, and these associations did not seem to be modified by HBR status. More intensified antiplatelet therapy may be beneficial for patients with complex percutaneous coronary revascularization procedures.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 63%

Section: Introductionmentioning

confidence: 99%

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Percutaneous Coronary Intervention Complexity and Risk of Adverse Events in Relation to High Bleeding Risk Among Patients Receiving Drug-Eluting Stents: Insights From a Large Single-Center Cohort Study

Wang

Dou

2020

Journal of the American College of Cardiology

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“…25 A recent study investigated the effects of ischaemic risk (eg the complexity of the procedure) and bleeding risk (according to the PRECISE-DAPT score) on clinical outcomes and on the impact of DAPT duration after PCI. 26 Ischaemic events were found to be more common in patients who underwent complex PCI. Therefore, it may be considered that these patients would benefit from extended DAPT.…”

Section: Discussionmentioning

confidence: 99%

Bleeding risk in patients with acute coronary syndrome in a Turkish population: Results from the Turkish Acute Coronary Syndrome Registry (TACSER) study

Avcı

Kırış

Akgün

et al. 2020

Eur J Clin Investigation

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Objective: Bleeding is one of the most important causes of mortality in patients with acute coronary syndrome (ACS). This study therefore aimed to investigate bleeding risk in patients with ACS who were scheduled to receive dual antiplatelet therapy (DAPT) in Turkey. Methods: This was a multicentre, observational, cross-sectional cohort study. The study population included 963 patients with ACS from 12 centres in Turkey. We used the Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score to predict the bleeding risk for all the patients. The patients were divided into high (≥25) or low (˂25) bleeding risk groups based on their PRECISE-DAPT scores. Results: The mean PRECISE-DAPT score was 21.9. Overall, 32.2% of the patients had high PRECISE-DAPT scores (≥25). Compared with the male patients, the female patients had higher PRECISE-DAPT scores (28.2 ± 15.7 vs 18.4 ± 13.6, P ˂ .001). Among the females, the rate of patients with a PRECISE-DAPT score ≥25 was 53%, while among the male patients, the score occurred at a rate of 22%. The female patients had lower haemoglobin (Hb) levels than the male patients (12.1 ± 1.7 vs 13.8 ± 1.9, P ˂ .001) and lower creatinine clearance (70.7 ± 27.5 vs 88.7 ± 26.3, P ˂ .001). The in-hospital bleeding rates were higher among the patients with high PRECISE-DAPT scores than among those who did not have high scores. Furthermore, the patients with high PRECISE-DAPT scores had a higher in-hospital mortality rate compared with those with low PRECISE-DAPT scores (1% vs 0%, P = .11). Conclusions: The mean PRECISE-DAPT score was high among the patients with ACS in this study, indicating that the bleeding tendency was high. This study showed 2 of 11 | AVCI et Al. How to cite this article: Avci E, Kiriş T, Akgün DE, et al. Bleeding risk in patients with acute coronary syndrome in a Turkish population: Results from the Turkish Acute Coronary Syndrome Registry (TACSER) study.

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“…12 Therefore, ischemic risk stratification, in addition to the suggested bleeding risk stratification, might require tailored DAPT regimens to consider the ischemic and bleeding risks in each clinical situation. 20 Bleeding events are ultimately associated with poor clinical outcomes. In the PARIS registry, disruptions because of bleeding or non-compliance were associated with a substantial increase in MACE.…”

Section: Study Limitationsmentioning

confidence: 99%

Efficacy and Safety of Guideline-Recommended Risk Score-Directed Dual Antiplatelet Therapy After 2nd-Generation Drug-Eluting Stents

Jang

Lee

Kim

et al. 2020

Circ J

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DES. Importantly, results have consistently shown that during longer DAPT, there is a trade-off between fewer ischemic events and increased bleeding events. 4 Alternatively, studies evaluating the clinical compatibility of short-term DAPT showed non-inferior clinical outcomes for patients with low thrombotic risk. 5-9 However, similar D ual antiplatelet therapy (DAPT) effectively treats ischemic heart disease by preventing thrombotic complications, especially after stent implantation. 1 With 1st-generation drug-eluting stents (DES), DAPT therapy was recommended for 12 months to prevent late or very late stent thrombosis (ST). 2 However, the clinical benefits of longer DAPT have been attenuated following the introduction of improved stent technology that has reduced thrombotic events, including the 2nd-generation Editorial p 153

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Dual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary Stenting

Cited by 227 publications

References 33 publications

Percutaneous Coronary Intervention Complexity and Risk of Adverse Events in Relation to High Bleeding Risk Among Patients Receiving Drug-Eluting Stents: Insights From a Large Single-Center Cohort Study

Percutaneous Coronary Intervention Complexity and Risk of Adverse Events in Relation to High Bleeding Risk Among Patients Receiving Drug-Eluting Stents: Insights From a Large Single-Center Cohort Study

Bleeding risk in patients with acute coronary syndrome in a Turkish population: Results from the Turkish Acute Coronary Syndrome Registry (TACSER) study

Efficacy and Safety of Guideline-Recommended Risk Score-Directed Dual Antiplatelet Therapy After 2nd-Generation Drug-Eluting Stents

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