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Kinlay S, Young MM, Sherrod R, Gagnon DR. Long-Term Outcomes and Duration of Dual Antiplatelet Therapy After Coronary Intervention With Second-Generation Drug-Eluting Stents: The Veterans Affairs Extended DAPT Study. J Am Heart Assoc 2023; 12:e027055. [PMID: 36645075 PMCID: PMC9939065 DOI: 10.1161/jaha.122.027055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background Recent guidelines on dual antiplatelet therapy (DAPT) duration after percutaneous coronary intervention (PCI) balance the subsequent risks of major bleeding with ischemic events. Although generally favoring shorter DAPT duration with second-generation drug-eluting stents, the effects on long-term outcomes in the wider population are uncertain. Methods and Results We tracked all patients having PCI with second-generation drug-eluting stents in the Veterans Affairs Healthcare System between 2006 and 2016 for death, myocardial infarction, stroke, and major bleeding up to 13 years. We compared these outcomes with 4 DAPT durations of 1 to 5, 6 to 9, 10 to 12, and 13 to 18 months after the index PCI using hazard ratios (HRs) and 95% CIs from Cox proportional hazards models adjusted by inverse probability weighting. A total of 40 882 subjects with PCI were followed up for a median of 4.3 (25%-75%: 2.4-6.5) years. DAPT discontinuation was rare early after PCI (5.8% at 1-5 months and 6.3% at 6-9 months) but increased (19% and 44%) >9 months. The risk of cardiovascular and noncardiovascular death was higher (HR, 2.03-3.41) with DAPT discontinuation <9 months, likely reflecting premature cessation from factors related to early death. DAPT discontinuation after 9 months following PCI was associated with lower risks of death (HR, 0.93 [95% CI, 0.88-0.99]), cardiac death (HR, 0.79 [95% CI, 0.70-0.90]), myocardial infarction (HR, 0.75 [95% CI, 0.69-0.82]), and major bleeding (HR, 0.82 [95% CI, 0.74-0.91]). Results were similar with an index PCI for an acute coronary syndrome. Conclusions Stopping DAPT after 9 months is associated with lower long-term risks of adverse ischemic and bleeding events and supports recent guidelines of shorter duration DAPT after PCI with second-generation drug-eluting stents.
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Affiliation(s)
- Scott Kinlay
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA,Harvard Medical SchoolBostonMA,Department of Biostatistics, Massachusetts Veterans Epidemiology Research & Information Center (MAVERIC)VA Boston Healthcare SystemBostonMA,Brigham and Women’s HospitalBostonMA,Boston University Medical SchoolBostonMA
| | - Melissa M. Young
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA,Department of Biostatistics, Massachusetts Veterans Epidemiology Research & Information Center (MAVERIC)VA Boston Healthcare SystemBostonMA
| | | | - David R. Gagnon
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA,Department of Biostatistics, Massachusetts Veterans Epidemiology Research & Information Center (MAVERIC)VA Boston Healthcare SystemBostonMA,Boston University School of Public HealthBostonMA
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2
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Vergara-Uzcategui CE, Moreno VH, Hennessey B, Sánchez-del-Hoyo R, Donis JH, Gonzalez-Rojas J, Salinas P, Nombela-Franco L, Gonzalo N, Jimenez-Quevedo P, Mejia-Renteria H, Escaned J, Fernández Ortiz A, Macaya Miguel C, Núñez-Gil IJ. Duration and clinical outcomes of dual antiplatelet therapy following percutaneous coronary intervention for acute coronary syndrome: A multicentre "real-world practice" registry-based study. Front Cardiovasc Med 2023; 10:1158466. [PMID: 37089881 PMCID: PMC10117825 DOI: 10.3389/fcvm.2023.1158466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Background The optimal duration of dual antiplatelet therapy (DAPT) ought to be determined taking into account individual ischaemic or bleeding events risks. To date, studies have provided inconclusive evidence on the effects of prolonged DAPT. We sought to evaluate the long-term outcomes of this strategy following percutaneous revascularization in the context of acute coronary syndrome (ACS). Methods Retrospectively from four centers in Madrid, we identified 750 consecutive ACS patients, divided in two groups of DAPT duration: <13 months and >13 months, with a mean follow-up of 48 months. Results Patients with DAPT > 13 months had a higher non-adjusted incidence of Major Adverse Cardiovascular Events (11.6% vs. 17.3%) and new revascularization (3.7% vs. 8.7%). Differences in all-cause death, cardiac death, myocardial infarction, stent thrombosis and stroke were non-significant. There was no difference in the incidence of major bleeding (7.4% vs. 6.3%). Multivariable Cox regression analysis showed that the independent risk predictors of MACE were age (HR: 1.04, 95% CI: 1.02-1.06, p < 0.001) and multivessel disease (HR: 2.29, 95% CI: 1.32-3.95, p = 0.003), whereas the independent protective predictor was normal hemoglobin (HR: 0.88, 95% CI: 0.78-0.98, p = 0.022). Conclusions In this real-world registry cohort of ACS patients treated with PCI and 1 year of DAPT in Spain, we report a trend of increased rate of MACE and new revascularization not associated with TVR in patients with longer DAPT. Our findings support the need for future randomized controlled trials to confirm or refute these results.
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Affiliation(s)
- Carlos E. Vergara-Uzcategui
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Víctor H. Moreno
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Breda Hennessey
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Rafael Sánchez-del-Hoyo
- Research methodological support unit and Preventive Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - José H. Donis
- Faculty of Medicine, Universidad de Los Andes, Mérida, Venezuela
| | | | - Pablo Salinas
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Nieves Gonzalo
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | | | | | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Antonio Fernández Ortiz
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Carlos Macaya Miguel
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Iván J. Núñez-Gil
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Spain
- Correspondence: Iván J. Núñez
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3
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Tavenier AH, Mehran R, Chiarito M, Cao D, Pivato CA, Nicolas J, Beerkens F, Nardin M, Sartori S, Baber U, Angiolillo DJ, Capodanno D, Valgimigli M, Hermanides RS, van 't Hof AWJ, Ten Berg JM, Chang K, Kini AS, Sharma SK, Dangas G. Guided and unguided de-escalation from potent P2Y12 inhibitors among patients with ACS: a meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:492-502. [PMID: 34459481 DOI: 10.1093/ehjcvp/pvab068] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/08/2021] [Accepted: 08/26/2021] [Indexed: 11/14/2022]
Abstract
AIM Optimal dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) intends to balance ischemic and bleeding risks. Various DAPT de-escalation strategies, defined as switching from a full-dose potent to a reduced dose or less potent P2Y12 inhibitor, have been evaluated in several ACS-PCI trials. We aimed to compare DAPT de-escalation to standard DAPT with full dose potent P2Y12 inhibitors in ACS patients who underwent PCI. METHODS & RESULTS PubMed, Google Scholar and Cochrane Central Register of Controlled Trials were searched for eligible randomised controlled trials. Aspirin monotherapy trials were excluded. Five randomised trials (n = 10,779 patients) that assigned DAPT de-escalation (genetically guided to clopidogrel n = 1,242; platelet function guided to clopidogrel n = 1,304; unguided to clopidogrel n = 1,672; unguided to lower dose n = 1,170) versus standard DAPT (control group n = 5,391) were included in this analysis. DAPT de-escalation was associated with a significant reduction in Bleeding Academic Research Consortium ≥ 2 bleeding (HR 0.57, 95% CI 0.42-0.78; I2 = 77%) as well as major adverse cardiac events, represented in most trials by the composite of cardiovascular mortality, myocardial infarction, stent thrombosis and stroke (HR 0.77, 95% CI 0.62-0.96; I2 = 0%). Notwithstanding the limited power, consistency was noted across various de-escalation strategies. CONCLUSION De-escalation of DAPT after PCI for ACS, both unguided and guided by genetic or platelet function testing, was associated with lower rates of clinically relevant bleeding and ischemic events as compared to standard DAPT with potent P2Y12 inhibitors based on five open-label RCTs reviewed.
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Affiliation(s)
- Anne H Tavenier
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Isala Heart Center, Zwolle, the Netherlands
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mauro Chiarito
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carlo A Pivato
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy.,Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | - Johny Nicolas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Frans Beerkens
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matteo Nardin
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Sartori
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Baber
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Marco Valgimigli
- Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Arnoud W J van 't Hof
- Isala Heart Center, Zwolle, the Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Jur M Ten Berg
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,St Antonius Hospital, Nieuwegein, the Netherlands
| | - Kiyuk Chang
- Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Annapoorna S Kini
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samin K Sharma
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George Dangas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Zheng YY, Wu TT, Guo QQ, Chen Y, Ma X, Ma YT, Zhang JY, Xie X. Long-term dual antiplatelet-induced intestinal injury resulting in translocation of intestinal bacteria into blood circulation increased the incidence of adverse events after PCI in patients with coronary artery disease. Atherosclerosis 2021; 328:1-10. [PMID: 34052667 DOI: 10.1016/j.atherosclerosis.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/04/2021] [Accepted: 04/21/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS The present study aimed to investigate the efficacy and safety of long-term (>18 months) dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). METHODS A total of 3205 coronary artery disease (CAD) patients after PCI from CORFCHD-PCI, a retrospective cohort study (Identifier: ChiCTR-ORC-16010153), were divided into two groups: monotherapy of aspirin or clopidogrel group (SAPT group, n = 2188 and DAPT group, n = 1017) according to whether to discontinue DAPT 18 months after PCI. After propensity matching analysis (PSM), we included 1017 patients in the DAPT group and 1017 patients in the SAPT group. All the patients were followed-up for at least 18 months and the longest follow-up time is 120 months. The primary endpoint was the incidence of major adverse cardiac events (MACEs). The secondary endpoints were the incidence of major adverse cardiovascular and cerebrovascular events (MACEEs) and bleeding events. We also selected 178 patients for detection of claudin-3 and intestinal fatty acid-binding protein and 58 patients for 16s RNA sequencing of whole blood. RESULTS The incidences of MACEs (13.9% vs. 9.0%, p = 0.001) and MACCEs (16.3% vs.10.0%, p < 0.001) were significantly increased in the DAPT group compared to the SAPT group. We also found DAPT increased the bleeding events compared to SAPT (4.6% vs. 2.9%, p = 0.048). Multivariate Cox regression analyses showed that in the DAPT group, cumulative risk of MACCEs increased 1.797 times (HR = 1.797, 95%CI: 1.429-2.226, p < 0.001), MACEs increased 1.737 times (HR = 1.737, 95%CI: 1.360-2.218, p < 0.001) and the bleeding events increased 2.129 times (HR = 2.129, 95%CI: 1.388-3.266, p = 0.001) compared to the SAPT group. We also found the plasma concentrations of claudin-3 and intestinal fatty acid-binding protein (I-FABP) were significantly higher in patients in the DAPT group compared with patients in the SAPT group (both p < 0.001). Correspondingly, the abundance of blood intestinal bacteria in the DAPT group was significantly increased compared to that in the SAPT group (p < 0.001). Furthermore, high-throughput metabolomics analysis suggested that serum level of ceramide (d18:1/16:0) and Neu5Ac was significantly increased in the DAPT group compared to the SAPT group (both p < 0.001). CONCLUSIONS The present study suggests that long-term dual antiplatelet therapy longer than 18 months significantly increases the incidence of both ischemic events and bleeding events after PCI. This preliminary study also indicates that long-term DAPT causes intestinal injury, which induces translocation of intestinal bacteria into the bloodstream.
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Affiliation(s)
- Ying-Ying Zheng
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, 450052, PR China.
| | - Ting-Ting Wu
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China
| | - Qian-Qian Guo
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, 450052, PR China
| | - You Chen
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China
| | - Xiang Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China
| | - Yi-Tong Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China
| | - Jin-Ying Zhang
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, 450052, PR China.
| | - Xiang Xie
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, PR China.
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5
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Kinlay S, Quach L, Cormack J, Morgenstern N, Hou Y, Young M, Sherrod R, Cho K, Faxon DP, Ramadan R, Gaziano M, Gagnon D. Premature Discontinuation of Dual Antiplatelet Therapy After Coronary Stenting in Veterans: Characteristics and Long-Term Outcomes. J Am Heart Assoc 2021; 10:e018481. [PMID: 33899501 PMCID: PMC8200740 DOI: 10.1161/jaha.120.018481] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/04/2021] [Indexed: 11/30/2022]
Abstract
Background Premature discontinuation of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention is related to higher short-term risks of adverse outcomes. Whether these risks persist in the long-term is uncertain. Methods and Results We assessed all patients having percutaneous coronary intervention with coronary second- or first-generation drug-eluting stents in the Veterans Affairs healthcare system between 2006 and 2012 who were free of major ischemic or bleeding events in the first 12 months. The characteristics of patients who stopped DAPT prematurely (1-9 months duration), compared with >9 to 12 months, or extended duration (>12 months) were assessed by odds ratios (ORs) from multivariable logistic models. The risk of adverse clinical outcomes over a mean 5.1 years in patients who stopped DAPT prematurely was assessed by hazard ratios (HRs) and 95% CIs from Cox regression models. A total of 14 239 had second-generation drug-eluting stents, and 8583 had first-generation drug-eluting stents. Premature discontinuation of DAPT was more likely in Black patients (OR, 1.54; 95% CI, 1.40-1.68), patients with greater frailty (OR, 1.04; 95% CI, 1.03-1.05), and patients with higher low-density lipoprotein cholesterol, and less likely in patients on statins (OR, 0.87; 95% CI, 0.80-0.95). Patients who stopped DAPT prematurely had higher long-term risks of death (second-generation drug-eluting stents: HR, 1.35; 95% CI, 1.19-1.56), myocardial infarction (second-generation drug-eluting stents: HR, 1.46; 95% CI, 1.22-1.74), and repeated coronary revascularization (second-generation drug-eluting stents: HR, 1.24; 95% CI, 1.08-1.41). Conclusions Patients who stop DAPT prematurely have features that reflect greater frailty, poorer medication use, and other social factors. They continue to have higher risks of major adverse outcomes over the long-term and may require more intensive surveillance many years after percutaneous coronary intervention.
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Affiliation(s)
- Scott Kinlay
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Brigham and Women’s HospitalBostonMA
- Harvard Medical SchoolBostonMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Lien Quach
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Jean Cormack
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Natalie Morgenstern
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Ying Hou
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Melissa Young
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | | | - Kelly Cho
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - David P. Faxon
- Brigham and Women’s HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Ronnie Ramadan
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Brigham and Women’s HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Michael Gaziano
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Brigham and Women’s HospitalBostonMA
- Harvard Medical SchoolBostonMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - David Gagnon
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
- Boston University School of Public HealthBostonMA
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