1
|
Ullah W, Zahid S, Sandhyavenu H, Faisaluddin M, Khalil F, Pasha AK, Alraies MC, Cuisset T, Rao SV, Sabouret P, Savage MP, Fischman DL. Extended, standard, or De-escalation antiplatelet therapy for patients with coronary artery disease undergoing percutaneous coronary intervention? A trial-sequential, bivariate, influential, and network meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:717-727. [PMID: 35325105 DOI: 10.1093/ehjcvp/pvac020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/02/2022] [Accepted: 03/16/2022] [Indexed: 06/14/2023]
Abstract
AIMS The relative safety and efficacy of de-escalation, extended duration (ED) (>12-months), and standard dual antiplatelet therapy for 12-months (DAPT-12) in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) remains controversial. METHODS AND RESULTS Online databases were queried to identify relevant randomized control trials (RCTs). ED-DAPT, high-potency (HP) DAPT, shorter duration (SD) DAPT, and low-dose (LD) DAPT were compared with DAPT-12. A trial sequential, bivariate, influential, and frequentist network meta-analysis (NMA) was performed to determine the pooled estimates. A total of 30 RCTs comprising 81 208 (40 839 experimental, 40 369 control arm) patients with CAD were included in the quantitative analysis. On NMA, compared with DAPT-12, all types of de-escalation, HP-DAPT-12, and ED-DAPT strategies had a statistically non-significant difference in the incidence of MACE at a median follow-up of 1-year. Similarly, there was no significant difference in the incidence of stroke, stent thrombosis, target lesion revascularization (TLR), target vessel revascularization (TVR), and all-cause mortality between DAPT-12 and all other strategies. The network estimates showed a significantly lower incidence of major bleeding with DAPT for 3-months followed by P2Y12-inhibitor monotherapy (RR 0.62, 95% CI 0.45-0.84), while a higher risk of bleeding with HP-DAPT for 12 months (RR 1.55, 95% CI 1.16-2.06). The net clinical benefit and rankograms also favoured DAPT-3 (P2Y12) and discouraged the use of HP-DAPT-12 and ED-DAPT. A subgroup analysis of 19 RCTs restricted to patients who presented with acute coronary syndrome (ACS) mirrored the findings of pooled analysis. A sensitivity analysis revealed no influence of any individual study or individual strategy on net ischemic estimates. The trial sequential analysis (TSA) illustrated a consistently non-significant difference at the interim analysis of trials, reaching the futility area for MACE, while the cumulative Z-values line surpassed the monitoring boundary as well as the required information size for major bleeding favouring de-escalation strategy. CONCLUSION DAPT for three months followed by ticagrelor-only and use of aspirin + clopidogrel after a short period of high potency DAPT appears to be a safe strategy for treating post-PCI patients. However, given the methodological limitations and inclusion of a small number of trials in novel de-escalation strategies, these findings need validation by future large scale RCTs.
Collapse
Affiliation(s)
- Waqas Ullah
- Division of Cardiology, Thomas Jefferson University Hospitals, 111 S 11th Street, Philadelphia, PA 19107, USA
| | - Salman Zahid
- Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621, USA
| | | | | | - Fouad Khalil
- Sanford School of Medicine, University of South Dakota, 1400 West 22nd Street, Sioux Falls, SD 57105, USA
| | - Ahmad K Pasha
- UHS Wilson Hospital, 33-57 Harrison Street, Johnson City, NY 13790, USA
| | - M Chadi Alraies
- Detroit Medical Center, Heart Hospital, 311 Mack Ave, Detroit, MI 48201, USA
| | - Thomas Cuisset
- Aix-Marseille University, 58 Boulevard Charles Livon, 13007 Marseille, France
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, NC, USA
| | - Pierre Sabouret
- Collège National des Cardiologues Français, 13 Rue Niépce, 75014 Paris, France
| | - Michael P Savage
- Division of Cardiology, Thomas Jefferson University Hospitals, 111 S 11th Street, Philadelphia, PA 19107, USA
| | - David L Fischman
- Division of Cardiology, Thomas Jefferson University Hospitals, 111 S 11th Street, Philadelphia, PA 19107, USA
| |
Collapse
|
2
|
Wang HY, Dou KF, Guan C, Xie L, Huang Y, Zhang R, Yang W, Wu Y, Yang Y, Qiao S, Gao R, Xu B. New Insights Into Long- Versus Short-Term Dual Antiplatelet Therapy Duration in Patients After Stenting for Left Main Coronary Artery Disease: Findings From a Prospective Observational Study. Circ Cardiovasc Interv 2022; 15:e011536. [PMID: 35582961 DOI: 10.1161/circinterventions.121.011536] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The appropriate duration of dual antiplatelet therapy (DAPT) and risk-benefit ratio for long-term DAPT in patients with left main (LM) disease undergoing percutaneous coronary intervention remains uncertain. METHODS Four thousand five hundred sixty-one consecutive patients with stenting of LM disease at a single center from January 2004 to December 2016 were enrolled. Decision to discontinue or remain on DAPT after 12 months was left to an individualized decision-making based on treating physicians by weighing the patient's risks of ischemia versus bleeding and considering patient preference. The primary outcome was a composite of death, myocardial infarction, stent thrombosis, or stroke at 3 years. Key safety outcome was 3-year rate of Bleeding Academic Research Consortium 2, 3, or 5 bleeding. RESULTS Of 3865 patients free of ischemic and bleeding events at 12 months, 1727 (44.7%) remained on DAPT (mostly clopidogrel based [97.7%]) beyond 12 months after LM percutaneous coronary intervention. DAPT>12-month versus ≤12-month DAPT was associated with a significant reduced risk of 3-year primary outcome (2.6% versus 4.6%; adjusted hazard ratio: 0.59 [95% CI, 0.41-0.84]). The same trend was found for other ischemic end points: death (0.9% versus 3.0%; Plog-rank<0.001), cardiovascular death (0.5% versus 1.7%; Plog-rank=0.001), myocardial infarction (0.8% versus 1.9%; Plog-rank=0.005), and stent thrombosis (0.4% versus 1.1%; Plog-rank=0.017). The key safety end point was not significantly different between 2 regimens (1.8% versus 1.6%; adjusted hazard ratio: 1.07 [95% CI, 0.65-1.74]). The effect of DAPT>12 month on primary and key safety outcomes was consistent across clinical presentations, high bleeding risk, P2Y12 inhibitor, and LM bifurcation percutaneous coronary intervention approach. CONCLUSIONS In a large cohort of patients free from clinical events during the first year after LM percutaneous coronary intervention and at low apparent future bleeding risk, an individualized patient-tailored approach to longer duration (>12 month) of DAPT with aspirin plus a P2Y12 inhibitor (mostly clopidogrel) improved both composite and individual efficacy outcomes by reducing ischemic risk, without a concomitant increase in clinically relevant bleeding.
Collapse
Affiliation(s)
- Hao-Yu Wang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.)
| | - Ke-Fei Dou
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.).,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Changdong Guan
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihua Xie
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunfei Huang
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Zhang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.)
| | - Weixian Yang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Yongjian Wu
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.).,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Yuejin Yang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.).,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Shubin Qiao
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Runlin Gao
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Bo Xu
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| |
Collapse
|
3
|
van Geuns RJ, Chun-Chin C, McEntegart MB, Merkulov E, Kretov E, Lesiak M, O’Kane P, Hanratty CG, Bressollette E, Silvestri M, Wlodarczak A, Barragan P, Anderson R, Protopopov A, Peace A, Menown I, Rocchiccioli P, Onuma Y, Oldroyd KG. Bioabsorbable polymer drug-eluting stents with 4-month dual antiplatelet therapy versus durable polymer drug-eluting stents with 12-month dual antiplatelet therapy in patients with left main coronary artery disease: the IDEAL-LM randomised trial. EUROINTERVENTION 2022; 17:1467-1476. [PMID: 35285803 PMCID: PMC9900447 DOI: 10.4244/eij-d-21-00514] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Improvements in drug-eluting stent design have led to a reduced frequency of repeat revascularisation and new biodegradable polymer coatings may allow a shorter duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). AIMS The Improved Drug-Eluting stent for All-comers Left Main (IDEAL-LM) study aims to investigate long-term clinical outcomes after implantation of a biodegradable polymer platinum-chromium everolimus-eluting stent (BP-PtCr-EES) followed by 4 months DAPT compared to a durable polymer cobalt-chromium everolimus-eluting stent (DP-CoCr-EES) followed by 12 months DAPT in patients undergoing PCI of unprotected left main coronary artery (LMCA) disease. METHODS This is a multicentre randomised clinical trial study in patients with an indication for coronary artery revascularisation who have been accepted for PCI for LMCA disease after Heart Team consultation. Patients were randomly assigned in a 1:1 ratio to receive either the BP-PtCr-EES or the DP-CoCr-EES. The primary endpoint was a non-inferiority comparison of the rate of major adverse cardiovascular events (MACE), defined as all-cause death, myocardial infarction, or ischaemia-driven target vessel revascularisation at 2 years. RESULTS Between December 2014 and October 2016, 818 patients (410 BP-PtCr-EES and 408 DP-CoCr-EES) were enrolled at 29 centres in Europe. At 2 years, the primary endpoint of MACE occurred in 59 patients (14.6%) in the BP-PtCr-EES group and 45 patients (11.4%) in the DP-CoCr-EES group; 1-sided upper 95% confidence interval (CI) 7.18%; p=0.04 for non-inferiority; p=0.17 for superiority. The secondary endpoint event of BARC 3 or 5 bleeding occurred in 11 patients (2.7%) in the BP-PtCr-EES group and 2 patients (0.5%) in the DP-CoCr-EES group (p=0.02). CONCLUSIONS In patients undergoing PCI of LMCA disease, after two years of follow-up, the use of a BP-PtCr-EES with 4 months of DAPT was non-inferior to a DP-CoCr-EES with 12 months of DAPT with respect to the composite endpoint of all-cause death, myocardial infarction or ischaemia-driven target vessel revascularisation.
Collapse
Affiliation(s)
- Robert-Jan van Geuns
- Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Chang Chun-Chin
- Department of Cardiology, Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands,Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Evgeny Merkulov
- Russian Cardiology Research Center, Moscow, Russian Federation
| | - Evgeny Kretov
- E.N. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Peter O’Kane
- Department of Cardiology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | | | | | | | - Adrian Wlodarczak
- Department of Cardiology, Miedziowe Centrum Zdrowia S.A., Lubin, Poland
| | - Paul Barragan
- Department of Cardiology, Polyclinique les Fleurs, Ollioules, France
| | | | | | - Aaron Peace
- Altnagelvin Hospital, Londonderry, United Kingdom
| | - Ian Menown
- Craigavon Area Hospital, Craigavon, United Kingdom
| | | | - Yoshinobu Onuma
- Department of Cardiology, Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands,Cardialysis, Rotterdam, the Netherlands
| | | |
Collapse
|
4
|
Capodanno D, Bhatt DL, Gibson CM, James S, Kimura T, Mehran R, Rao SV, Steg PG, Urban P, Valgimigli M, Windecker S, Angiolillo DJ. Bleeding avoidance strategies in percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:117-132. [PMID: 34426673 DOI: 10.1038/s41569-021-00598-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 02/08/2023]
Abstract
For many years, bleeding has been perceived as an unavoidable consequence of strategies aimed at reducing thrombotic complications in patients undergoing percutaneous coronary intervention (PCI). However, the paradigm has now shifted towards bleeding being recognized as a prognostically unfavourable event to the same extent as having a new or recurrent ischaemic or thrombotic complication. As such, in parallel with progress in device and drug development for PCI, there is clinical interest in developing strategies that maximize not only the efficacy but also the safety (for example, by minimizing bleeding) of any antithrombotic treatment or procedural aspect before, during or after PCI. In this Review, we discuss contemporary data and aspects of bleeding avoidance strategies in PCI, including risk stratification, timing of revascularization, pretreatment with antiplatelet agents, selection of vascular access, choice of coronary stents and antithrombotic treatment regimens.
Collapse
Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera italiana (USI), Lugano, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | | |
Collapse
|