Optimal Strategy for Antiplatelet Therapy After Coronary Drug-Eluting Stent Implantation in High-Risk “TWILIGHT-like” Patients With Diabetes Mellitus

Abstract

Background: Patients with diabetes mellitus (DM) are known to be at high-risk for both ischemic and bleeding complications post-percutaneous coronary intervention (PCI). The ischemic benefit vs. bleeding risk associated with extended dual antiplatelet therapy (DAPT) in high-risk “TWILIGHT-like” patients with diabetes mellitus after PCI has not been established.Methods: All consecutive high-risk patients fulfilling the “TWILIGHT-like” criteria undergoing PCI from January 2013 through December 2013 were identified from the prospective Fuwai PCI Registry. High-risk “TWILIGHT-like” patients were defined by at least one clinical and one angiographic feature based on the TWILIGHT trial selection criteria. The present analysis evaluated 3,425 diabetic patients with concomitant high-risk angiographic features who were event-free at 1 year after PCI. Median follow-up was 2.4 years. The primary effectiveness endpoint was a composite of death, myocardial infarction, or stroke (termed major adverse cardiac and cerebrovascular events), and primary safety endpoint was clinically relevant bleeding according to the Bleeding Academic Research Consortium types 2, 3, or 5.Results: On inverse probability of treatment weighting (IPTW) analysis, prolonged-term (>1-year) DAPT with aspirin and clopidogrel decreased the risk of primary effectiveness endpoint compared with shorter ( ≤ 1-year) DAPT [1.8 vs. 4.3%; hazard ratio (HR)IPTW: 0.381; 95% confidence interval (CI): 0.252–0.576; P < 0.001] and reduced cardiovascular death [0.1% vs. 1.8%; HRIPTW: 0.056 (0.016–0.193)]. Prolonged DAPT was also associated with a reduced risk of definite/probable stent thrombosis [0.2 vs. 0.7%; HRIPTW: 0.258 (0.083–0.802)] and non-significantly lower rate of myocardial infarction [0.5 vs. 0.8%; HRIPTW: 0.676 (0.275–1.661)]. There was no significant difference between groups in clinically relevant bleeding [1.1 vs. 1.1%; HRIPTW: 1.078 (0.519–2.241); P = 0.840). Similar results were observed in multivariable Cox proportional hazards regression model.Conclusion: Among high-risk PCI patients with diabetes mellitus without an adverse event through 1 year, extending DAPT >1-year significantly reduced the risk of major adverse cardiac and cerebrovascular events without an increase in clinically relevant bleeding, suggesting that such high-risk diabetic patients may be good candidates for long-term DAPT.

Effect of dual antiplatelet therapy prolongation in acute coronary syndrome patients with both high ischemic and bleeding risk: insight from the OPT-CAD study

“…The inconsistent results and lower incidence of bleeding and ischemic events might contribute to a high proportion of bleeding and ischemic events, which might contribute to a high proportion of the trial population treated with prasugrel, ethnic differences, procedural improvements, and changes in bleeding avoidance strategies over time. Nevertheless, the incidence of ischemic and bleeding events in the present study was similar to that observed between 1 and 2 years after PCI in other trials involving East Asian populations (18,19). Considering the contemporary clinical practice, extended P2Y12 inhibitor monotherapy with clopidogrel might be an optimal antiplatelet strategy.…”

Benefit and Risk of Prolonged Dual Antiplatelet Therapy After Percutaneous Coronary Intervention With Drug-Eluting Stents in Patients With Elevated Lipoprotein(a) Concentrations

“…Covariates used for the propensity score model included age, sex, body mass index, current smoker, diabetes, hypertension, dyslipidemia, previous MI, previous PCI, previous stroke, peripheral vascular disease, chronic obstructive pulmonary disease, total cholesterol, LDL-C, total lesion length, type B2 or C lesion, chronic total occlusion (CTO), bifurcation lesion, number of lesions treated, stent number, use of everolimus-or zotarolimus-eluting stent, and use of aspirin, P2Y 12 inhibitor, β-blocker, and statin at discharge. The detailed methods of IPTW analysis were previously described (26).…”

How Do Lipoprotein(a) Concentrations Affect Clinical Outcomes for Patients With Stable Coronary Artery Disease Who Underwent Different Dual Antiplatelet Therapy After Percutaneous Coronary Intervention?

“…This was an analysis of a single center, prospective study, and the study design has been previously described. 17 , 18 Patients with stable CAD who underwent PCI with DES implantation at Fuwai Hospital, National Center for Cardiovascular Diseases, between January 2013 and December 2013 were selected. Stable CAD refers to patients with CAD who are clinically stable (ie, who are not in an unstable phase such as an acute coronary syndrome [ACS]).…”

“…The detailed methods of IPTW analysis were previously described. 18 All statistical analyses were conducted with SPSS version 23.0 (IBM, Armonk, NY) and R version 3.6.0 (R Foundation for Statistical Computing, Vienna, Austria). A 2‐sided P value of <0.05 was considered statistically significant.…”