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Kumar A, Shariff M, Singal A, Bhat V, Stulak J, Reed G, Kalra A. A Bayesian meta-analysis of double kissing (DK) crush or provisional stenting for coronary artery bifurcation lesions. Indian Heart J 2024; 76:113-117. [PMID: 38537883 PMCID: PMC11143502 DOI: 10.1016/j.ihj.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVE Despite the development of dedicated, two-stent strategies, including the double kissing (DK) crush technique, the ideal technique for coronary artery bifurcation stenting has not been identified. We aimed to compare and determine the absolute risk difference (ARD) of the DK crush technique alone versus provisional stenting approaches for coronary bifurcation lesions, using the Bayesian technique. METHOD We queried PubMed/MEDLINE to identify randomized controlled trials (RCTs) that compared DK crush technique with provisional stenting for bifurcation lesions, published till January 2023. We used Bayesian methods to calculate the ARD and 95% credible interval (CrI). RESULTS We included three RCTs, with 916 patients, in the final analysis. The ARD of cardiac death was centered at -0.01 (95% CrI: -0.04 to 0.02; Tau: 0.02, 85% probability of ARD of DK crush vs. provisional stenting <0). ARD for myocardial infarction was centered at -0.03 (95%CrI: -0.9 to 0.03; Tau: 0.05, 87% probability of ARD of DK crush vs. provisional stenting <0). ARD for stent thrombosis was centered at 0.00 (95% CrI: -0.04 to 0.03, Tau: 0.03, 51% probability of ARD for DK crush vs. provisional stenting <0). Finally, ARD for target lesion revascularization was centered at -0.05 (95% CrI: -0.08 to -0.03, Tau: 0.02, 99.97% probability of ARD for DK crush vs. provisional stenting <0). CONCLUSIONS Bayesian analysis demonstrated a lower probability of cardiac death, myocardial infarction and target lesion revascularization, with DK crush compared with provisional stenting techniques, and a minimal probability of difference in stent thrombosis.
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Affiliation(s)
- Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mariam Shariff
- Department of General Surgery, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Aayush Singal
- Department of Cardiology, Aakash Healthcare, New Delhi, India
| | - Vivek Bhat
- Department of Medicine, St. John's Medical College, Bangalore, India
| | - John Stulak
- Department of General Surgery, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Grant Reed
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ankur Kalra
- Franciscan Health, Lafayette, IN, USA; Krannert Cardiovascular Research Center, Indianapolis, IN, USA.
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2
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Paradies V, Banning A, Cao D, Chieffo A, Daemen J, Diletti R, Hildick-Smith D, Kandzari DE, Kirtane AJ, Mehran R, Park DW, Tarantini G, Smits PC, Van Mieghem NM. Provisional Strategy for Left Main Stem Bifurcation Disease: A State-of-the-Art Review of Technique and Outcomes. JACC Cardiovasc Interv 2023; 16:743-758. [PMID: 37045495 DOI: 10.1016/j.jcin.2022.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 04/14/2023]
Abstract
Left main coronary artery (LMA) disease jeopardizes a large area of myocardium and increases the risk of major adverse cardiovascular events. LMCA disease is found in 5% to 7% of all diagnostic coronary angiographies, and more than 80% of the patients enrolled in recent large randomized controlled left main trials had distal left main bifurcation or trifurcation disease. Emerging clinical evidence from prospective all-comer registries and randomized trials has provided a solid basis for percutaneous coronary intervention as a treatment option in selected patients with unprotected LMCA disease; however, to date, no uniform recommendations as to optimal stenting strategy for LMCA bifurcation lesions exist. This review provides an overview of provisional stenting technique and escalation to 2-stent strategies in LMCA bifurcation lesions. Data from randomized controlled trials and registries are reviewed. Technical characteristics of optimal provisional LMCA stenting technique and angiographic and intravascular determinants of escalation are also summarized.
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Affiliation(s)
- Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands; Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, the Netherlands
| | - Adrian Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom; Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Davide Cao
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; Cardio Center, Humanitas Research Hospital IRCCS, Milan, Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, the Netherlands
| | - David Hildick-Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | | | - Ajay J Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, the Netherlands.
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Cho S, Kang DY, Kim JS, Park DW, Kim IS, Kang TS, Ahn JM, Lee PH, Kang SJ, Lee SW, Kim YH, Lee CW, Park SW, Lee SJ, Hong SJ, Ahn CM, Kim BK, Ko YG, Choi D, Jang Y, Hong MK, Park SJ. Tratamiento antiagregante plaquetario doble tras la intervención coronaria percutánea del tronco coronario izquierdo. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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4
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Dual antiplatelet therapy after percutaneous coronary intervention for left main coronary artery disease. REVISTA ESPAÑOLA DE CARDIOLOGÍA (ENGLISH EDITION) 2022; 76:245-252. [PMID: 35907438 DOI: 10.1016/j.rec.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/15/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES There are scarce data on the optimal duration and prognostic impact of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with second-generation drug-eluting stents for left main coronary artery (LMCA) disease. The aim of this study was to investigate the practice pattern and long-term prognostic effect of DAPT duration in patients undergoing PCI with second-generation drug-eluting stents for LMCA disease. METHODS Using individual patient-level data from the IRIS-MAIN and KOMATE registries, 1827 patients undergoing PCI with second-generation drug-eluting stents for LMCA disease with valid information on DAPT duration were included. The efficacy outcome was major adverse cardiovascular events (MACE, a composite of cardiac death, myocardial infarction, and stent thrombosis) and the safety outcome was TIMI major bleeding. RESULTS DAPT duration was <6 months (n=273), 6 to 12 months (n=477), 12 to 24 months (n=637), and ≥ 24 months (n=440). The median follow-up duration was 3.9 [interquartile range, 3.01-5.00] years. Prolonged DAPT duration was associated with lower incidences of MACE. In multigroup propensity score analysis, adjusted HR for MACE were significantly higher for DAPT <6 months and DAPT 6 to 12 months than for DAPT 12 to 24 months (HR, 4.51; 95%CI, 2.96-6.88 and HR 1.92; 95%CI, 1.23-3.00). There was no difference in HR for major bleeding among the assessed groups. CONCLUSIONS DAPT duration following PCI for LMCA disease is highly variable. Although the duration of DAPT should be considered in the context of the clinical situation of each patient, <12 months of DAPT was associated with higher incidence of MACE. Registration identifiers: NCT01341327; NCT03908463.
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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.
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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.)
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Outcomes of prolonged dual anti-platelet therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A nationwide registry-based study. Am Heart J 2022; 245:81-89. [PMID: 34902311 DOI: 10.1016/j.ahj.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 09/29/2021] [Accepted: 11/20/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Randomized controlled trials have shown a reduced risk of ischemic events and an increased risk of bleeding in patients treated with prolonged dual anti-platelet therapy (DAPT) beyond 12 months following acute coronary syndrome (ACS). We aimed to investigate outcomes of prolonged DAPT vs aspirin monotherapy (ASA) in a real-world population. METHODS AND RESULTS Using nationwide registries, we identified all patients with ACS who underwent percutaneous coronary intervention and received 12-month DAPT between January 2013 and October 2016. Patients still on DAPT were compared to patients on ASA at index date (15 months after ACS-date) and followed for up to 2 years. Cox regression models were employed to calculate standardized risks of all-cause mortality, major adverse cardiovascular event (MACE), and major bleeding. The study included 7,449 patients, 1,901 on DAPT (median age 66, 72.1% male) and 5,548 on ASA (median age 65, 75.1% male). Standardized absolute 2-year risk of all-cause mortality, MACE, and major bleeding was 2.7%, 3.7%, and 5.4% for DAPT vs 2.2%, 3.8%, and 1.3% for ASA. DAPT was not associated with a significant standardized 2-year risk difference (SRD) of all-cause mortality (SRD: 0.5%, 95% confidence interval [CI]: -0.9 to 1.7) or MACE (SRD: -0.1%, 95% CI -1.8 to 1.6), but a significantly higher risk of major bleeding (SRD: 4.1%, 95% CI 1.8-6.6). CONCLUSIONS In a nationwide cohort of ACS patients undergoing percutaneous coronary intervention, prolonged DAPT was not significantly associated with a reduced risk of all-cause mortality or MACE, but an increased risk of major bleeding. Future randomized controlled trials should investigate the optimal anti-platelet regimen in this patient group.
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Boswell MR, Smith MM, Frank RD, Brown MJ, Abcejo AS, Kor TM, Gulati R, Smith BB. Association Between Antifibrinolytic Therapy and Perioperative Outcomes in Patients With Coronary Artery Stents Undergoing Noncardiac Surgery. Anesth Analg 2021; 132:1635-1644. [PMID: 33780399 PMCID: PMC8154652 DOI: 10.1213/ane.0000000000005522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients with existing coronary artery stents are at an increased risk for major adverse cardiac events (MACEs) when undergoing noncardiac surgery (NCS). Although the use of antifibrinolytic (AF) therapy in NCS has significantly increased in the past decade, the relationship between perioperative AF use and its association with MACEs among patients with existing coronary artery stents has yet to be assessed. In this study, we aim to evaluate the association of MACEs in patients with existing coronary artery stents who receive perioperative AF therapy during orthopedic surgery. METHODS A single-center retrospective cohort study was conducted in adult patients with existing coronary artery stents who underwent orthopedic surgery from 2008 to 2018. Two cohorts were established: patients with existing coronary artery stents who did not receive perioperative AF and patients with coronary artery stents who received perioperative AF. Associations between AF use and the primary outcome of MACEs within 30 days postoperatively and the secondary outcomes of thrombotic complications, excessive surgical bleeding, and intensive care unit (ICU) admissions were analyzed using logistic regression models. Inverse probability of treatment weighting was used to control for confounding. Secondary analyses examining the association between coronary stent type/timing and the outcomes of interest were performed using unadjusted logistic regression models. RESULTS A total of 473 patients met study criteria, including 294 who did not receive AF and 179 patients who received AF. MACEs occurred in 15 (5.1%) patients who did not receive AF and 1 (0.6%) who received AF (P = .007). In weighted analyses, no significant difference was found in patients who received AF with regard to MACEs (odds ratio [OR] = 0.13, 95% confidence interval [CI], 0.01-1.74, P = .12), thrombotic complications (OR = 1.19, 95% CI, 0.53-2.68, P = .68), or excessive surgical bleeding (OR = 0.13, 95% CI, 0.01-2.23, P = .16) compared to patients who did not receive AF. CONCLUSIONS The results of this study are inconclusive whether an association exists between perioperative AF use in patients with coronary artery stents and the outcome of MACEs compared to patients who did not receive perioperative AF therapy. The authors acknowledge that the imprecise CI hinders the ability to definitively determine whether an association exists in the study population. Further large prospective studies, powered to detect differences in MACEs, are needed to assess the safety of perioperative AF in patients with existing coronary artery stents and to clarify the mechanism of perioperative MACEs in this high-risk population.
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Affiliation(s)
- Michael R. Boswell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark M. Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan D. Frank
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Michael J. Brown
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Arnoley S. Abcejo
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Todd M. Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Internal Medicine, Division of Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Bradford B. Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
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Choi J, Kim IS, Cho S, Kim JS, Hong SJ, Shin DH, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Jang Y. Optimal Duration for Dual Antiplatelet Therapy After Left Main Coronary Artery Stenting. Circ J 2020; 85:59-68. [PMID: 33281141 DOI: 10.1253/circj.cj-20-0362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Coronary interventions using drug-eluting stents (DESs) of left main coronary artery (LMCA) lesions have shown favorable clinical outcomes. However, duration of dual antiplatelet therapy (DAPT) after LMCA interventions has not yet been investigated.Methods and Results:From a multicenter Korean Multicenter Angioplasty Team (KOMATE) registry, 1,004 patients who received DES implantations for LMCA lesions and did not experience major adverse cardiovascular events (including major bleeding) for 1 year after coronary intervention were analyzed. Patients were divided into 2 groups; DAPT ≤12 (n=503) and >12 months (n=501). The primary endpoint was number of net clinical adverse events (NACEs), composite of cardiac deaths, myocardial infarctions, stent thrombosis and major bleeding events. During a 4.5-year follow-up period after LMCA interventions, the DAPT >12 months group showed a lower NACE rate than the DAPT ≤12 months group (adjusted-HR 0.53 [0.29-0.99], P=0.045). For patients who maintained DAPT >12 months, rate of cardiac deaths, myocardial infarctions, and stent thrombosis events were lower than in patients who had DAPT ≤12 months (adjusted-HR 0.35 [0.17-0.73], P=0.005) without increased major bleeding (P=0.402). CONCLUSIONS For patients who can continue DAPT without major bleeding events, prolonged DAPT (>12 months) after LMCA stenting demonstrated better long-term efficacy outcomes than DAPT ≤12 months with comparable safety.
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Affiliation(s)
- Jungho Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine.,Division of Cardiology, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine
| | - In-Soo Kim
- Division of Cardiology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine
| | - Sungsoo Cho
- Division of Cardiovascular Medicine, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Dong-Ho Shin
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
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9
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So HS, So MG, Kang SI, Park JI, Lee JH, Kim U, Park JS. Long-Term Safety and Efficacy of Extended Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation in Real-World Practice. Circ J 2020; 84:2175-2184. [PMID: 33162461 DOI: 10.1253/circj.cj-20-0668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Extended dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is frequently used for high-risk patients in real-world practice. However, there are limited data about the long-term efficacy of extended DAPT after percutaneous coronary intervention (PCI).Methods and Results:This study investigated 1,470 patients who underwent PCI. The study population was divided into 2 groups based on DAPT duration: guideline-based DAPT (G-DAPT; DAPT ≤12 months after PCI; n=747) and extended DAPT (E-DAPT; DAPT >12 months after PCI; n=723). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCEs), defined as cardiac death, myocardial infarction (MI), repeat target vessel revascularization, or stroke. The median follow-up duration was 80.8 months (interquartile range 60.6-97.1 months). The incidence of MACCE was similar in the G-DAPT and E-DAPT groups (21.0% vs. 18.3%, respectively; P=0.111). However, the E-DAPT group had a lower incidence of non-fatal MI (hazard ratio [HR] 0.535; 95% confidence interval [CI] 0.329-0.869; P=0.011), and target lesion revascularization (HR 0.490; 95% CI 0.304-0.792; P=0.004), and stent thrombosis (HR 0.291; 95% CI 0.123-0.688; P=0.005). The incidence of bleeding complications, including major bleeding, was similar between the 2 groups (5.2% vs. 6.3%, respectively; P=0.471). CONCLUSIONS Although E-DAPT after DES implantation was not associated with a reduced rate of MACCE, it was associated with a significantly lower incidence of non-fatal MI, TLR, and stent thrombosis.
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Affiliation(s)
| | | | | | - Jong-Il Park
- Yeungnam University College of Medicine.,Cardiovascular Division, College of Medicine, Yeungnam University Medical Center
| | - Jung-Hee Lee
- Yeungnam University College of Medicine.,Cardiovascular Division, College of Medicine, Yeungnam University Medical Center
| | - Ung Kim
- Yeungnam University College of Medicine.,Cardiovascular Division, College of Medicine, Yeungnam University Medical Center
| | - Jong-Seon Park
- Yeungnam University College of Medicine.,Cardiovascular Division, College of Medicine, Yeungnam University Medical Center
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Wang HY, Dou KF, Wang Y, Yin D, Xu B, Gao RL. Benefit-Risk Profile of DAPT Continuation Beyond 1 Year after PCI in Patients with High Thrombotic Risk Features as Endorsed by 2018 ESC/EACTS Myocardial Revascularization Guideline. Cardiovasc Drugs Ther 2020; 34:663-675. [PMID: 32601780 DOI: 10.1007/s10557-020-07030-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The ischemic/bleeding trade-off of continuing dual antiplatelet therapy (DAPT) beyond 1 year after PCI for patients with high thrombotic risk (HTR) as endorsed by 2018 ESC/EACTS myocardial revascularization guidelines remain unknown. METHODS Patients undergoing coronary stenting between January 2013 and December 2013 from the prospective Fuwai registry were defined as HTR if they met at least 1 ESC/EACTS guideline-endorsed HTR criteria. A total of 4578 patients who were at HTR and were events free at 1 year after the index procedure were evaluated. The primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE) (composite of all-cause death, myocardial infarction, or stroke). RESULTS Median follow-up period was 2.4 years. > 1-year DAPT with clopidogrel and aspirin significantly reduced the risk of MACCE compared with ≤ 1-year DAPT (1.9% vs. 4.6%; hazard ratio (HR): 0.38; 95% confidence interval (CI): 0.27-0.54; P < 0.001), driven by a reduction in all-cause death (0.2% vs. 3.0%; HR, 0.07; 95% CI, 0.03-0.15). Cardiac death and definite/probable stent thrombosis also occurred less frequently in prolonged DAPT group. Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding occurred similarly between both groups (1.1% vs. 0.9%; HR, 1.11; 95% CI, 0.58-2.13; P = 0.763). Similar results were found using multivariable Cox model, propensity score-matched, and inverse probability of treatment weighting analysis. CONCLUSIONS Among patients with ESC-endorsed HTR who were free from major ischemic or bleeding events 1 year after coronary stenting, continued DAPT beyond 1 year might offer better effectiveness in terms of atherothrombotic events and comparable safety in terms of clinically relevant bleeding compared with ≤ 1-year DAPT. ESC-HTR criteria is an important parameter to take into account in tailoring DAPT prolongation.
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Affiliation(s)
- Hao-Yu Wang
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ke-Fei Dou
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China. .,State Key Laboratory of Cardiovascular Disease, Beijing, China. .,National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Yin
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Bo Xu
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China.,Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Run-Lin Gao
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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11
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Wang HY, Gao RL, Xu B, Yang YJ, Yin D, Wang Y, Dou KF. Benefit-risk profile of extended dual antiplatelet therapy beyond 1 year in patients with high risk of ischemic or bleeding events after PCI. Platelets 2020; 32:533-541. [PMID: 32498587 DOI: 10.1080/09537104.2020.1774052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The benefits and harms of dual antiplatelet therapy (DAPT) continuation with aspirin and clopidogrel beyond 1 year after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation for high ischemic or bleeding risk patients remain unclear. All consecutive patients undergoing PCI were prospectively included in the Fuwai PCI Registry from January 2013 to December 2013. We evaluated 7521 patients who were at high risk for thrombotic or hemorrhagic complications and were events free at 1 year after the index procedure. "TWILIGHT-like" patients with high risk of bleeding or ischemic events were defined by clinical and angiographic criteria. The primary ischemic outcome was major adverse cardiac and cerebrovascular events [MACCE] (a composite of all-cause death, myocardial infarction, or stroke). Median follow-up duration was 2.4 years. The risk of MACCE was significantly lower in DAPT>1-year group (n = 5252) than DAPT≤1-year group (n = 2269) (1.5% vs. 3.8%; hazard ratio [HR]: 0.37; 95% confidence interval [CI]: 0.27-0.50; P < .001). This difference was largely driven by a lower risk of all-cause death. In contrast, the risk of Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding was statistically similar between the two groups (1.0% vs. 1.1%; HR: 0.80; 95% CI: 0.50-1.28; P = .346). Results were consistent after multivariable regression and propensity-score matching. Prolonged DAPT beyond 1 year after DES implantation resulted in a significantly lower rate of atherothrombotic events, including a mortality benefit, with no higher risk of clinically relevant bleeding in "TWILIGHT-like" patients who were at high-risk for ischemic or bleeding events.
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Affiliation(s)
- Hao-Yu Wang
- Department of Cardiology, Coronary Heart Disease Center, 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.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Run-Lin Gao
- Department of Cardiology, Coronary Heart Disease Center, 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
| | - Bo Xu
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China.,Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Jin Yang
- Department of Cardiology, Coronary Heart Disease Center, 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
| | - Dong Yin
- Department of Cardiology, Coronary Heart Disease Center, 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
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke-Fei Dou
- Department of Cardiology, Coronary Heart Disease Center, 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.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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12
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Rigatelli G, Zuin M, Vassilev D, De Ferrari GM, D'Ascenzo F. Outcomes of Left Main Bifurcation Stenting Depends on Both Length of Dual Antiplatelet Therapy and Stenting Strategy. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1319-1322. [PMID: 32247565 DOI: 10.1016/j.carrev.2020.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 01/11/2023]
Abstract
Data regarding the optimal dual antiplatelet therapy (DAPT) duration in patients treated with a 1- versus a 2-stent strategy in LM bifurcation PCI are scant. A literature search based on Cochrane Library, Embase, PubMed and Google Scholar was performed to locate articles published between January 2015 and January 2020. The following MeSH terms were used for the search: "Left Main" AND "DAPT Duration" AND "stent" OR "stenting". The analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Occurrence of major adverse cardiovascular events (MACEs) according to length of DAPT and stenting strategy was analysed. A total of 256 articles were retrieved and after evaluation, 3 articles evaluating the results of 8 large registries were included into the analysis including a final population of 4117 patients [mean age 65.7 years, 3133 (76.0%) males]. A short-term DAPT resulted in a lower risk of MACEs in patients treated with a single stent strategy (OR: 0.49, 95% CI [0.33-0.67], p < 0.001, I2 = 0%), whereas a DAPT >12 months resulted in a significant higher risk of MACEs in the same group (OR: 7.39, 95% CI [5.09-10.7], p < 0.001, I2 = 61%) compared to double stent strategy. The available data support the use of short DAPT in single cross-over LM stenting whereas a long DAPT seems to be more appropriate after a double stenting strategy in LM bifurcation PCI.
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Affiliation(s)
- Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy.
| | - Marco Zuin
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy; University of Ferrara, School of Medicine, Ferrara, Italy
| | - Dobrin Vassilev
- Department of Cardiology, Alexandrovska University Hospital, Sofia, Bulgaria
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy; Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan; Division of Cardiology, Universityspirtal of Zürich, Zürich, Switzerland
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