Very short vs. long dual antiplatelet therapy after second generation drug-eluting stents in 35 785 patients undergoing percutaneous coronary interventions: a meta-analysis of randomized controlled trials

Benenati, Stefano; Galli, Mattía; Marzo, Vincenzo De; Pescetelli, Fabio; Toma, Matteo; Andreotti, Felicita; Bona, Roberta Della; Canepa, Marco; Ameri, Pietro; Crea, Filippo; Porto, Italo

doi:10.1093/ehjcvp/pvaa001

Cited by 36 publications

(21 citation statements)

References 31 publications

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“…Recent evidence has shown net benefits in the ischemic/bleeding balance for short (≤6 months) vs. 12 months DAPT in patients with low ischemic risk [ 94 , 95 ]. Seven major RCTs published in recent years and evaluating a very short DAPT (1 or 3 months) after stenting as compared to 12-month therapy [ 60 , 61 , 96 , 97 , 98 , 99 , 100 ] were analyzed together in a recent metanalysis [ 101 ]. Interestingly, very short DAPT yielded comparable rates of all-cause mortality, stent thrombosis, and major acute cardiovascular endpoints than 12 months DAPT.…”

Section: Treatment Strategies After Bleedingmentioning

confidence: 99%

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Acute Coronary Syndrome, Antiplatelet Therapy, and Bleeding: A Clinical Perspective

Tersalvi

Biasco

Cioffi

et al. 2020

JCM

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Inhibition of platelet function by means of dual antiplatelet therapy (DAPT) is the cornerstone of treatment of acute coronary syndrome (ACS). While preventing ischemic recurrences, inhibition of platelet function is clearly associated with an increased bleeding risk, a feared complication that may lead to significant morbidity and mortality. Since bleeding risk management is intrinsically associated with therapeutic adjustments undertaken during the whole clinical history of patients with acute coronary syndrome, single decisions taken from the very first day to years of follow-up might be decisive. This review aims at providing a clinically oriented, patient-tailored approach in reducing the risk and manage bleeding complications in ACS patients treated with DAPT. The steps in clinical decision making from the day of ACS to follow-up are analyzed. New treatment strategies to enhance the safety of DAPT are also described.

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Section: Treatment Strategies After Bleedingmentioning

confidence: 99%

“…At the same time, very short DAPT was associated with reduced rates of major bleeding or any bleeding. Subgroup analyses showed consistent results for 1 vs. 3 month DAPT and for aspirin vs. P2Y12 inhibitor monotherapy following very short DAPT [ 101 ].…”

Section: Treatment Strategies After Bleedingmentioning

confidence: 99%

Acute Coronary Syndrome, Antiplatelet Therapy, and Bleeding: A Clinical Perspective

Tersalvi

Biasco

Cioffi

et al. 2020

JCM

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“…5 In fact, most patients with stable atherosclerotic vascular disease who are treated with aspirin remain at risk of ischemic recurrences and alternative strategies, including DAPT, have not shown to be of clinical benefit. 24,25 In COMPASS, a total of 27,395 patients were randomly assigned to receive rivaroxaban 2.5 mg/bid plus aspirin (i.e., DPI), rivaroxaban 5 mg/bid, or aspirin. 5 While rivaroxaban 5 mg/bid did not significantly reduce ischemic events, DPI was associated with a 24% reduction of MACE (composite of cardiovascular death, stroke, or myocardial infarction) compared with aspirin alone.…”

Section: Discussionmentioning

confidence: 99%

“…strategies, including DAPT, have not shown to be of clinical benefit 24,25 . In COMPASS, a total of 27,395 were randomly assigned to receive rivaroxaban 2.5 mg/bid plus aspirin (i.e., DPI), rivaroxaban 5 mg/bid, or aspirin 5 .…”

Section: Accepted Manuscriptmentioning

confidence: 99%

Pharmacodynamic Profiles of Dual-Pathway Inhibition with or without Clopidogrel versus Dual Antiplatelet Therapy in Patients with Atherosclerotic Disease

et al. 2022

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Aim: Inhibition of thrombin-mediated signaling processes using a vascular dose of rivaroxaban in adjunct to antiplatelet therapy, known as dual-pathway inhibition (DPI), reduces atherothrombotic events in patients with stable atherosclerotic disease. However, there are limited data on the pharmacodynamic (PD) effects of this strategy. Methods and Results: This investigation was conducted in selected cohorts of patients (n=40) with stable atherosclerotic disease enrolled within a larger prospective PD study who were treated with either aspirin plus clopidogrel (DAPT), aspirin plus rivaroxaban 2.5 mg/bid (DPI) or DAPT plus rivaroxaban 2.5 mg/bid. Multiple PD assays assessing of markers of thrombosis were used. PD endpoints included platelet-mediated global thrombogenicity measured by light transmittance aggregometry (LTA) following stimuli with CATF [collagen‐related peptide +adenosine diphosphate (ADP) +tissue factor (TF)], markers of P2Y12 reactivity, markers of platelet aggregation using LTA following several stimuli (arachidonic acid, ADP, collagen, TF, and TRAP), thrombin generation and thrombus formation. There was no difference in platelet-mediated global thrombogenicity between groups. Rivaroxaban significantly reduced thrombin generation and was associated with a trend towards reduced TF-induced platelet aggregation. Clopidogrel-based treatments reduced markers of P2Y12 signaling and TRAP‐induced platelet aggregation. There were no differences between groups on markers of cyclooxygenase‐1 mediated activity. Conclusions: Compared with DAPT, DPI does not result in any differences in platelet-mediated global thrombogenicity, but reduces thrombin generation. These PD observations support that modulating thrombin generation by means of factor Xa inhibition in adjunct to antiplatelet therapy provides effective antithrombotic effects, supporting the efficacy and safety findings of DPI observed in clinical

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“…In general, prolonged DAPT after PCI is related to significantly increased risk of bleeding compared to short or standard DAPT ( 30 ). However, the results of this study demonstrated that the significant reduction of ischemic events by prolonged DAPT in diabetic patients led to favorable outcome including reduced mortality, overwhelming the numerically, but statistically not significant, increased bleeding events.…”

Section: Discussionmentioning

confidence: 99%

Prolonged dual antiplatelet therapy after drug-eluting stent implantation in patients with diabetes mellitus: A nationwide retrospective cohort study

Lee

Choi

Kim

et al. 2022

Front. Cardiovasc. Med.

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BackgroundOptimal duration of dual antiplatelet therapy (DAPT) in patients with diabetes mellitus (DM) who have undergone drug-eluting stent (DES) implantation is not clearly established. This study sought to impact of DAPT duration on real-world clinical outcome in patients with or without DM.MethodsUsing a nationwide cohort database, we investigate the association between DAPT duration and clinical outcome between 1 and 3 years after percutaneous coronary intervention (PCI). Primary outcome was all-cause death. Secondary outcomes were cardiovascular death, myocardial infarction, and composite bleeding events. After weighting, 90,100 DES-treated patients were included; 29,544 patients with DM and 60,556 without DM; 31,233 patients with standard DAPT (6–12 months) and 58,867 with prolonged DAPT (12–24 months).ResultsThe incidence of all-cause death was significantly lower in patients with prolonged DAPT [8.3% vs. 10.5% in those with standard DAPT, hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.72–0.84] in diabetic patients and non-diabetic patients (4.5% vs. 5.0% in those with standard DAPT, HR 0.89, 95% CI 0.83–0.96). The incidence of composite bleeding events was 5.7% vs. 5.4%, respectively, (HR 1.07, 95% CI 0.96–1.18) in diabetic patients and 5.6% vs. 5.0%, respectively, in non-diabetic patients (HR 1.13, 95% CI 1.05–1.21). There was a significant interaction between the presence of DM and DAPT duration for all-cause death (p for interaction, pint = 0.01) that further favored prolonged DAPT in diabetic patients. However, there was no significant interaction between the presence of DM and DAPT duration for composite bleeding events (pint = 0.38).ConclusionsThis study showed that prolonged rather than standard DAPT might be clinically beneficial in diabetic patients with DES implantation.Trial registrationClinicalTrial.gov (NCT04715594).

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Very short vs. long dual antiplatelet therapy after second generation drug-eluting stents in 35 785 patients undergoing percutaneous coronary interventions: a meta-analysis of randomized controlled trials

Cited by 36 publications

References 31 publications

Acute Coronary Syndrome, Antiplatelet Therapy, and Bleeding: A Clinical Perspective

Acute Coronary Syndrome, Antiplatelet Therapy, and Bleeding: A Clinical Perspective

Pharmacodynamic Profiles of Dual-Pathway Inhibition with or without Clopidogrel versus Dual Antiplatelet Therapy in Patients with Atherosclerotic Disease

Prolonged dual antiplatelet therapy after drug-eluting stent implantation in patients with diabetes mellitus: A nationwide retrospective cohort study

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