Prolonged dual antiplatelet therapy in invasively treated acute coronary syndrome patients with different lipoprotein(a) concentrations

Abstract

Background Lipoprotein(a) [Lp(a)] was positively associated with recurrent ischemic events in patients with acute coronary syndrome (ACS). This study was performed to investigate the effect of Lp(a) levels on outcomes of dual antiplatelet therapy (DAPT) > 1 year versus DAPT ≤ 1 year after percutaneous coronary intervention (PCI) in this population. Methods A total of 4,357 ACS patients who were event-free at 1 year after PCI were selected from the Fuwai PCI Registry, and patients were stratified into four groups according to DAPT duration (≤ 1 year vs. > 1 year) and Lp(a) levels (≤ 30 mg/dL vs. > 30 mg/dL). The primary endpoint was major adverse cardiovascular and cerebrovascular event (MACCE), defined as a composite of cardiac death, myocardial infarction or stroke. Results After 2.4-year follow-up, the incidence of MACCE (hazard ratio [HR] adjusted 0.284, 95% confidence interval [CI] 0.115–0.700; HR IPTW 0.351, 95% CI 0.164–0.751) were significantly reduced in DAPT > 1 year group than that in DAPT ≤ 1 year group in individuals with elevated Lp(a) levels. However, in individuals with normal Lp(a) levels, no statistically difference was found between these two groups in terms of MACCE, although the risks of all-cause death and definite/probable stent thrombosis were lower in DAPT > 1 year group. Notably, the risk of clinically relevant bleeding did not statistically differ between these two groups in individuals with different Lp(a) levels. Conclusions This study firstly demonstrated that extended DAPT (> 1 year) was statistically associated with lower risk of ischemic events in ACS patients with elevated Lp(a) levels after PCI, whereas this association was not found in individuals with normal Lp(a) levels.

Should dual antiplatelet treatment be guided by lipoprotein(a) concentration?

“…Recently Cui et al [ 2 ] reported secondary analysis of a single-center, prospective registry demonstrating that extended (> 1 year) dual antiplatelet therapy (DAPT) was associated with lower risk of ischemic cardiovascular events in patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) with elevated Lp(a) levels, but not in individuals with normal Lp(a) level. The extended DAPT was not associated with increased risk of clinically relevant bleeding and did not differ between the two groups with different Lp(a) levels.…”

“…The extended DAPT was not associated with increased risk of clinically relevant bleeding and did not differ between the two groups with different Lp(a) levels. This study is the first one evaluating the effect of Lp(a) concentrations on the clinical outcomes of extended DAPT in ACS patients after PCI [ 2 ]. The present study has several limitations, including the specific Asian ethnicity of the patients, but it provides a strong rationale for more complex assessment of lipid parameters including Lp(a) in all currently ongoing and planned clinical trials aimed at assessing DAPT modification, especially de-escalation and prolonged treatment [ 3 – 7 ].…”

Lipoprotein(a): an important consideration for DAPT therapy after PCI

“…The interest in the letter is much appreciated for the study assessing the effect of extended dual antiplatelet therapy (DAPT) on clinical outcomes in invasively treated acute coronary syndrome (ACS) patients with different lipoprotein(a) [Lp(a)] concentrations [ 1 ]. Previous in vivo and in vitro studies revealed that Lp(a) has a pro-aggregatory effect through proteinase-activated receptor 1 (PAR1) via thrombin-mediated activation and CD36 via OxPL-mediated activation [ 2 – 3 ] and an anti-aggregatory effect through platelet-activating factor acetylhydrolase (PAFAH), collagen and αIIbβ3 integrin [ 4 – 5 ].…”

Lipoprotein(a) as a risk factor for cardiovascular diseases - focus on ischemic stroke (a position paper)

“…Можно предполагать, что это вопрос будущего. Тем не менее именно у пациентов с высокой концентрацией Лп(а) более длительная двойная антитромбоцитарная терапия может иметь преимущества [68]. Так, например, в исследовании PEGASUS-TIMI 54 (тикагрелор в дополнение к терапии ацетилсалициловой кислотой) были показаны различия в риске развития «больших» кардиоваскулярных событий в зависимости от уровня ЛП(а).…”