Duration of Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation

Giustino, Gennaro; Baber, Usman; Sartori, Samantha; Mehran, Roxana; Mastoris, Ioannis; Kini, Annapoorna; Sharma, Samin K.; Pocock, Stuart J.; Dangas, George

doi:10.1016/j.jacc.2015.01.039

Cited by 317 publications

(88 citation statements)

References 32 publications

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“…13 The lower rates of major bleeding with shorter DAPT compared with longer DAPT in the recent meta-analysis might partly explain the reduction in noncardiac mortality. 25,26 Finally, DES type has been shown to affect the benefit derived from prolonging DAPT 26 ; this study extends this clinical impression to the modern BP-DES types.…”

Section: Discussionsupporting

confidence: 53%

Six Versus 12 Months of Dual Antiplatelet Therapy After Implantation of Biodegradable Polymer Sirolimus-Eluting Stent

Han

et al. 2016

Circ: Cardiovascular Interventions

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D rug-eluting stent (DES) use during percutaneous coronary intervention (PCI) has resulted in improved clinical outcomes compared with bare metal stents.1,2 However, late stent thrombosis after DES remains a concern.3,4 Although current guidelines recommend prolonged dual antiplatelet therapy (DAPT) for all patients undergoing implantation ofBackground-There are no reports on a large-scale randomized trial exploring optimal dual antiplatelet therapy (DAPT) duration after biodegradable polymer sirolimus-eluting stent implantation. We sought to report the outcomes of a randomized substudy of the prospective Evaluate Safety and Effectiveness of the Tivoli DES and the Firebird DES for Treatment of Coronary Revascularization (I-LOVE-IT 2) trial. Methods and Results-In the prospective noninferiority randomized I-LOVE-IT 2 trial, 1829 patients allocated to the biodegradable polymer sirolimus-eluting stent group were also randomized to receive either 6-month (n=909) or 12-month DAPT (n=920). The primary end points of this noninferiority substudy were 12-month target lesion failure (composite of cardiac death, target vessel myocardial infarction or clinically indicated target lesion revascularization), and the major secondary end points were 12-month net adverse clinical and cerebral events (composite of all-cause death, all myocardial infarction, stroke, or major bleeding [Bleeding Academic Research Consortium type ≥3]). The 12-month target lesion failure in 6-month DAPT group was comparable with the 12-month DAPT group (6.8% versus 5.9%; difference and 95% confidence interval, 0.87% [−1.37% to 3.11%], P for noninferiority=0.0065). Further followup at 18 months showed that incidence of target lesion failure and net adverse clinical and cerebral events were similar between the 2 groups (7.5% versus 6.3%, log-rank P=0.32; 7.8% versus 7.3%, log-rank P=0.60; respectively), as well as their individual end point components. Conclusions-This study indicated noninferiority in safety and efficacy of 6-month versus 12-month DAPT after implantation of a novel biodegradable polymer sirolimus-eluting stent. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01681381.(Circ Cardiovasc Interv. 2016;9:e003145.

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Section: Discussionsupporting

confidence: 53%

Six Versus 12 Months of Dual Antiplatelet Therapy After Implantation of Biodegradable Polymer Sirolimus-Eluting Stent

Han

et al. 2016

Circ: Cardiovascular Interventions

Self Cite

134

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“…Finally, in randomized trials, prolonged DAPT has been associated with increased all-cause mortality because of greater noncardiovascular mortality, not offset by reduced cardiovascular mortality, reinforcing the need for an individualized risk-based approach to DAPT duration. [36][37][38] Collectively, these data suggest that a shorter DAPT duration (3-6 months) after EES may be preferred in patients without excessive ongoing ischemic risk.…”

Section: Downloaded From Stent Thrombosis and Dapt Interruptionmentioning

confidence: 88%

Stent Thrombosis and Dual Antiplatelet Therapy Interruption With Everolimus-Eluting Stents

Généreux

Rutledge

Palmerini

et al. 2015

Circ: Cardiovascular Interventions

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C urrent guidelines recommend dual antiplatelet therapy (DAPT) for at least 6 months (European Securities Committee)1 and 1 year (American College of Cardiology/ American Heart Association/Society for Cardiac Angiography and Interventions) 2 after drug-eluting stents (DES) to prevent stent thrombosis (ST), based on studies suggesting that firstgeneration DES are associated with increased rates of ST with premature DAPT discontinuation.3-6 Compared with bare-metal stents and first-generation DES, cobalt-chromium everolimus-eluting stent (CoCr-EES) has in several reports been associated with the lowest rates of early, late, and very late ST. [7][8][9][10] As prolonged use of DAPT has been associated with a significant risk of major bleeding, 11,12 knowing whether short-term DAPT might be safe in patients treated with EES is Background-Whether premature dual antiplatelet therapy (DAPT) interruption is safe in patients receiving cobalt chromium everolimus-eluting stents remains controversial. We sought to examine the relationship between DAPT discontinuation and stent thrombosis (ST) after cobalt chromium everolimus-eluting stents. Methods and Results-Outcomes from 11 219 patients were pooled from 3 randomized trials and 4 registries with 2-year follow-up period after cobalt chromium everolimus-eluting stent implantation. . Conclusions-In this large pooled experience, permanent DAPT discontinuation before 30 days after cobalt chromium everolimus-eluting stent implantation was strongly associated with ST, whereas DAPT discontinuation beyond 90 days appeared safe.

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“…12 Ten randomized trials and 32 135 patients were included in the analysis (Table 1). Short-duration DAPT, by definition 3, 6, or 12 months after the procedure, compared with long-duration DAPT, defined as 18 to 30 months after stent implantation, had a higher rate of definite or probable ST (odds ratio, 1.71; 95% confidence interval [CI], 1.26-2.32; P=0.001), particularly among patients with first-generation DES compared with those with second-generation DES (odds ratio, 3.94; 95% CI, 2.20-7.05; P int =0.008; Figure 1 and Table 2).…”

Section: Shorter Is Sufficientmentioning

confidence: 99%

Are at Least 12 Months of Dual Antiplatelet Therapy Needed for All Patients With Drug-Eluting Stents?

Becker

Helmy

2015

Circulation

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1T he optimal duration of dual antiplatelet therapy (DAPT) after coronary arterial stenting is an important question for clinicians and patients alike and represents a dynamic state of benefit and risk to achieve optimal outcomes. Clinicians must carefully balance the risk for future coronary arteryrelated events with an assessment of bleeding risk and, in many instances, recognize a changing risk-benefit relationship from the time of stent implantation. Patients must work closely with their healthcare providers to understand their medical condition-the basis for and importance of the treatments recommended-and to openly share their values, preferences, and anticipated obstacles to adhering to medical advice, including cost and limited access to ambulatory clinics in the community. The debate over duration of therapy comes at a time when national health care is facing serious challenges, with costs to individual patients contributing to an increasing divide among social classes in the United States and abroad.2 It also presents an opportunity to honor a pragmatic side of precision medicine as a priority for population health and the scientific community. What Is the Goal of DAPT After Stent Implantation?As with other blood-contacting medical devices, thrombosis is the predominant cause of failure after stent implantation. Accordingly, the goal of antithrombotic therapy in general and DAPT in particular is to reduce the risk of cardiovascular events, including stent thrombosis (ST), 4,5 a life-threatening emergency. This is particularly important in the early time period 6,7 after procedure-related vascular injury and before strut endothelialization 8 when ST is most likely to occur.9,10 Prevention of ischemic and thrombotic events outside of or at a distance from the stented site is also a potential goal of therapy, particularly over the ensuing weeks and months.

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Duration of Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation

Cited by 317 publications

References 32 publications

Six Versus 12 Months of Dual Antiplatelet Therapy After Implantation of Biodegradable Polymer Sirolimus-Eluting Stent

Six Versus 12 Months of Dual Antiplatelet Therapy After Implantation of Biodegradable Polymer Sirolimus-Eluting Stent

Stent Thrombosis and Dual Antiplatelet Therapy Interruption With Everolimus-Eluting Stents

Are at Least 12 Months of Dual Antiplatelet Therapy Needed for All Patients With Drug-Eluting Stents?

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