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Khelimskii D, Bessonov I, Sapozhnikov S, Badoyan A, Baranov A, Mamurjon M, Manukian S, Utegenov R, Krestyaninov O. Impact of Prolonged Dual Antiplatelet Therapy After Bifurcation Percutaneous Coronary Intervention in Patients with High Ischemic Risk. Am J Cardiovasc Drugs 2024; 24:577-588. [PMID: 38871947 DOI: 10.1007/s40256-024-00657-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of prolonged dual antiplatelet therapy (DAPT) on clinical outcomes in patients undergoing percutaneous coronary interventions (PCI) for bifurcation coronary lesions. METHODS A total of 1000 patients who underwent PCI for coronary bifurcation lesions and had clinical follow-up were divided into two groups based on the duration of DAPT: DAPT > 12 months and DAPT ≤ 12 months). Patients who experienced a myocardial infarction, required repeat PCI, or died within 1 year after the initial procedure were excluded. RESULTS Among the 1000 eligible patients, 394 patients received DAPT for > 12 months (39.4%). Most patients in our study presented with chronic coronary disease (61%). The majority of patients in our study (62.8%) had a low bleeding risk. The median follow-up duration was 35 months (interquartile range 20.6-36.5). There were no significant differences in the major adverse cardiovascular events (MACE) between groups of prolonged DAPT (> 12 month) and DAPT ≤ 12 months (18.8% vs. 14.9%, p = 0.11). Patients with clinical features of high ischemic risk (HIR) had a significantly increased risk of MACE (hazard ratio [HR] 1.92, 95% confidence interval [CI] 1.12-3.26, p = 0.015) when compared with patients without clinical features of HIR. Compared with DAPT ≤ 12 months, extended DAPT (> 12 months) did not improve outcomes in patients with clinical (HR 1.24, 95% CI 0.90-1.72, p = 0.19) and technical features (HR 1.04, 95% CI 0.67-1.63, p = 0.85) of HIR. CONCLUSION In this multicenter real-world registry, administration of DAPT for more than 12 months in patients who have undergone PCI for bifurcation lesion is not associated with a reduced incidence of MACE in long-term follow-up. REGISTRATION ClinicalTrials.gov identifier no. NCT03450577.
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Affiliation(s)
- Dmitrii Khelimskii
- Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, 15 Rechkunovskaya st., Novosibirsk, 630055, Russian Federation.
| | - Ivan Bessonov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, 625026, Russian Federation
| | - Stanislav Sapozhnikov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, 625026, Russian Federation
| | - Aram Badoyan
- Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, 15 Rechkunovskaya st., Novosibirsk, 630055, Russian Federation
| | - Aleksey Baranov
- Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, 15 Rechkunovskaya st., Novosibirsk, 630055, Russian Federation
| | - Mahmudov Mamurjon
- Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, 15 Rechkunovskaya st., Novosibirsk, 630055, Russian Federation
| | - Serezha Manukian
- Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, 15 Rechkunovskaya st., Novosibirsk, 630055, Russian Federation
| | - Ruslan Utegenov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, 625026, Russian Federation
| | - Oleg Krestyaninov
- Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, 15 Rechkunovskaya st., Novosibirsk, 630055, Russian Federation
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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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Cirillo P, DI Serafino L, Gamra H, Zimarino M, Barbato E, Briguori C, Amat-Santos IJ, Chieffo A, Erglis A, Gil RJ, Kedev SA, Petrov I, Radico F, Niglio T, Nakamura S, Costa RA, Kanic V, Perfetti M, Pellicano M, Maric K, Tesorio T, Vukcevic V, Esposito G, Stankovic G. Impact of dual antiplatelet therapy duration on clinical outcome after coronary bifurcation stenting: results from the EuroBifurcation Club registry. Panminerva Med 2023; 65:1-12. [PMID: 35546730 DOI: 10.23736/s0031-0808.22.04604-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) of a bifurcation stenosis is still debated. We evaluated the impact of DAPT duration on clinical outcomes in all-comers patients undergoing bifurcation PCI included in the European Bifurcation Club (EBC) registry. METHODS We enrolled 2284 consecutive patients who completed at least 18 months follow-up. The cumulative occurrence of major adverse cardiac and cardiovascular events (MACCE), defined as a composite of overall-death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and stroke were evaluated. Bleedings classified as Bleeding Academic Research Consortium (BARC) ≥3 were evaluated too. RESULTS Patients were divided into 3 groups: short DAPT (<6-months, N.=375); standard DAPT (≥6-months but ≤12-months, N.=636); prolonged DAPT (>12-months, N.=1273). At 24 months follow-up MACCE-free survival was significantly lower in short DAPT patients (Log-Rank: 45.23, P for trend <0.001). MACCE occurred less frequently in the prolonged DAPT group (148 [11.6%]) as compared with both the short (83 [22.1%] HR: 0.48 [0.37-0.63], P<0.001) and standard DAPT groups (137 [21.5%] HR:0.51 [0.41-0.65], P<0.001). These differences remain after propensity score adjustment (respectively, HR: 0.27 [0.20-0.36] and HR: 0.44 [0.34-0.57]). Such finding was consistent in patients presenting with both acute and chronic coronary syndromes. BARC≥3 bleedings were 0.3% in the standard DAPT, 1.6% in short and 1.9% in prolonged DAPT groups. CONCLUSIONS In the "real-world" EBC registry of patients undergoing PCI of coronary artery bifurcation stenosis, a prolonged DAPT duration was associated with a significantly lower risk of MACCE and a potential increased risk of major bleedings.
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Affiliation(s)
- Plinio Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy -
| | - Luigi DI Serafino
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Habib Gamra
- Department of Cardiology, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Marco Zimarino
- Institute of Cardiology, G. D'Annunzio University, Chieti, Italy.,Interventional Cath Lab, ASL 2 Abruzzo, Chieti, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.,CIBERCV, University Clinical Hospital of Valladolid, Valladolid, Spain
| | | | | | - Alaide Chieffo
- Unit of Interventional Cardiology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Robert J Gil
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland
| | - Sasko A Kedev
- University Clinic of Cardiology Skopje, Skopje, Macedonia
| | | | - Francesco Radico
- Institute of Cardiology, G. D'Annunzio University, Chieti, Italy
| | - Tullio Niglio
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Sunao Nakamura
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | | | - Vojko Kanic
- Department of Cardiology and Angiology, University Medical Centre, Maribor, Slovenia
| | | | - Mariano Pellicano
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.,CIBERCV, University Clinical Hospital of Valladolid, Valladolid, Spain.,Laboratory of Invasive Cardiology, Montevergine Clinic, Mercogliano, Avellino, Italy
| | - Kristina Maric
- Department of Cardiovascular Medicine, University Hospital Centre, Zagreb, Croatia
| | - Tullio Tesorio
- Laboratory of Invasive Cardiology, Montevergine Clinic, Mercogliano, Avellino, Italy
| | - Vladan Vukcevic
- Department of Cardiology, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
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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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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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Zhang S, Chourase M, Sharma N, Saunik S, Duggal M, Danaei G, Duggal B. The effects of dual antiplatelet therapy (DAPT) adherence on survival in patients undergoing revascularization and the determinants of DAPT adherence. BMC Cardiovasc Disord 2022; 22:238. [PMID: 35606724 PMCID: PMC9125829 DOI: 10.1186/s12872-022-02677-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence and burden of coronary heart disease (CHD) has increased substantially in India, accompanied with increasing need for percutaneous coronary interventions (PCI). Although a large government-funded insurance scheme in Maharashtra, India covered the cost of PCI for low-income patients, the high cost of post-PCI treatment, especially Dual Antiplatelet Therapy (DAPT), still caused many patients to prematurely discontinue the secondary prevention. Our study aimed to investigate the effectiveness of DAPT adherence on all-cause mortality among post-PCI patients and explore the potential determinants of DAPT adherence in India. METHOD We collected clinical data of 4,595 patients undergoing PCI in 110 participating medical centers in Maharashtra, India from 2012 to 2015 by electronic medical records. We surveyed 2527 adult patients who were under the insurance scheme by telephone interview, usually between 6 to 12 months after their revascularization. Patients reporting DAPT continuation in the telephone survey were categorized as DAPT adherence. The outcome of the interest was all-cause mortality within 1 year after the index procedure. Multivariate Cox proportional hazard (PH) model with adjustment of potential confounders and standardization were used to explore the effects of DAPT adherence on all-cause mortality. We further used a multivariate logistic model to investigate the potential determinants of DAPT adherence. RESULTS Out of the 2527 patients interviewed, 2064 patients were included in the analysis, of whom 470 (22.8%) discontinued DAPT prematurely within a year. After adjustment for baseline confounders, DAPT adherence was associated with lower one-year all-cause mortality compared to premature discontinuation (less than 6-month), with an adjusted hazard ratio (HR) of 0.52 (95% Confidence Interval (CI) = (0.36, 0.67)). We also found younger patients (OR per year was 0.99 (0.97, 1.00)) and male (vs. female, OR of 1.30 (0.99, 1.70)) had higher adherence to DAPT at one year as did patients taking antihypertensive medications (vs. non medication, OR of 1.57 (1.25, 1.95)). CONCLUSION These findings suggest the protective effects of DAPT adherence on 1-year mortality among post-PCI patients in a low-income setting and indicate younger age, male sex and use of other preventive treatments were predictors of higher DAPT adherence.
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Affiliation(s)
- Shuqi Zhang
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, USA
| | | | - Nupur Sharma
- Health Technology Assessment Hub, AIIMS Rishikesh, Rishikesh, India
| | | | - Mona Duggal
- Department of Community Medicine, PGIMER, Chandigarh, India
| | - Goodarz Danaei
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, USA.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, USA
| | - Bhanu Duggal
- Department of Cardiology, AIIMS Rishikesh, Rishikesh, India.
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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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De Filippo O, Kang J, Bruno F, Han JK, Saglietto A, Yang HM, Patti G, Park KW, Parma R, Kim HS, De Luca L, Gwon HC, Iannaccone M, Chun WJ, Smolka G, Hur SH, Cerrato E, Han SH, di Mario C, Song YB, Escaned J, Choi KH, Helft G, Doh JH, Truffa Giachet A, Hong SJ, Muscoli S, Nam CW, Gallone G, Capodanno D, Trabattoni D, Imori Y, Dusi V, Cortese B, Montefusco A, Conrotto F, Colonnelli I, Sheiban I, de Ferrari GM, Koo BK, D'Ascenzo F. Benefit of Extended Dual Antiplatelet Therapy Duration in Acute Coronary Syndrome Patients Treated with Drug Eluting Stents for Coronary Bifurcation Lesions (from the BIFURCAT Registry). Am J Cardiol 2021; 156:16-23. [PMID: 34353628 DOI: 10.1016/j.amjcard.2021.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/22/2021] [Accepted: 07/01/2021] [Indexed: 11/15/2022]
Abstract
Optimal dual antiplatelet therapy (DAPT) duration for patients undergoing percutaneous coronary intervention (PCI) for coronary bifurcations is an unmet issue. The BIFURCAT registry was obtained by merging two registries on coronary bifurcations. Three groups were compared in a two-by-two fashion: short-term DAPT (≤ 6 months), intermediate-term DAPT (6-12 months) and extended DAPT (>12 months). Major adverse cardiac events (MACE) (a composite of all-cause death, myocardial infarction (MI), target-lesion revascularization and stent thrombosis) were the primary endpoint. Single components of MACE were the secondary endpoints. Events were appraised according to the clinical presentation: chronic coronary syndrome (CCS) versus acute coronary syndrome (ACS). 5537 patients (3231 ACS, 2306 CCS) were included. After a median follow-up of 2.1 years (IQR 0.9-2.2), extended DAPT was associated with a lower incidence of MACE compared with intermediate-term DAPT (2.8% versus 3.4%, adjusted HR 0.23 [0.1-0.54], p <0.001), driven by a reduction of all-cause death in the ACS cohort. In the CCS cohort, an extended DAPT strategy was not associated with a reduced risk of MACE. In conclusion, among real-world patients receiving PCI for coronary bifurcation, an extended DAPT strategy was associated with a reduction of MACE in ACS but not in CCS patients.
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Affiliation(s)
- Ovidio De Filippo
- Department of Medical Sciences, Division of Cardiology, University of Turin, Torino, Italy.
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Francesco Bruno
- Department of Medical Sciences, Division of Cardiology, University of Turin, Torino, Italy
| | - Jung-Kyu Han
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Andrea Saglietto
- Department of Medical Sciences, Division of Cardiology, University of Turin, Torino, Italy
| | - Han-Mo Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Giuseppe Patti
- Coronary Care Unit and Catheterization laboratory, A.O.U. Maggiore della Carità, Novara, Novara, Italy
| | - Kyung-Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Radoslaw Parma
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Leonardo De Luca
- Department of Cardiosciences, A.O. San Camillo-Forlanini, Roma, Italy
| | - Hyeon-Cheol Gwon
- Department of Cardiology, Sungkyunkwan University Samsung Medical Center Seoul Republic of Korea
| | - Mario Iannaccone
- Dipartimento di Cardiologia, Ospedale San Giovanni Bosco,Torino, Italy
| | - Woo Jung Chun
- Department of Internal Medicine, Samsung Changwon Hospital, Changwon, Republic of Korea
| | - Grzegorz Smolka
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Seung-Ho Hur
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Enrico Cerrato
- Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Seung Hwan Han
- Department of Internal Medicine, Division of Cardiology, Gachon University Gil Hospital, Incheon, Republic of Korea
| | - Carlo di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Young Bin Song
- Department of Cardiology, Sungkyunkwan University Samsung Medical Center Seoul Republic of Korea
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Ki Hong Choi
- Department of Cardiology, Sungkyunkwan University Samsung Medical Center Seoul Republic of Korea
| | - Gerard Helft
- Pierre and Marie Curie University, Paris, France
| | - Joon-Hyung Doh
- Department of Internal Medicine, Division of Cardiology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | | | - Soon-Jun Hong
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Saverio Muscoli
- Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | - Chang-Wook Nam
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Guglielmo Gallone
- Department of Medical Sciences, Division of Cardiology, University of Turin, Torino, Italy
| | - Davide Capodanno
- Department of Cardio-Thoracic-Vascular , Division of Cardiology, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele," Catania, Italy
| | - Daniela Trabattoni
- Invasive Cardiology Unit 3, Centro Cardiologico Monzino, IRCCS, Milano, Italy
| | - Yoichi Imori
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Veronica Dusi
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
| | - Bernardo Cortese
- Department of Interventional Cardiology, ASST Fatebenefratelli-Sacco, Milano, Italy
| | - Antonio Montefusco
- Department of Medical Sciences, Division of Cardiology, University of Turin, Torino, Italy
| | - Federico Conrotto
- Department of Medical Sciences, Division of Cardiology, University of Turin, Torino, Italy
| | | | | | | | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Fabrizio D'Ascenzo
- Department of Medical Sciences, Division of Cardiology, University of Turin, Torino, Italy
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10
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Varlamos C, Lianos I, Benetou DR, Alexopoulos D. Left Main Disease and Bifurcation Percutaneous Coronary Intervention: Focus on Antithrombotic Therapy. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Revascularization of both left main and bifurcation lesions is currently considered an important feature of complex percutaneous coronary intervention (PCI), whereas stenting distal left main bifurcation is fairly challenging. Recent evidence shows that such lesions are associated with an increased risk of ischemic events. There is no universal consensus on the optimal PCI strategy or the appropriate type and duration of antithrombotic therapy to mitigate the thrombotic risk. Prolonged dual antiplatelet therapy or use of more potent P2Y12 inhibitors have been investigated in the context of this high-risk subset of the population undergoing PCI. Thus, while complex PCI is a growing field in interventional cardiology, left main and bifurcation PCI constitutes a fair amount of the total complex procedures performed recently, and there is cumulative interest regarding antithrombotic therapy type and duration in this subset of patients, with decision-making mostly based on clinical presentation, baseline bleeding, and ischemic risk, as well as the performed stenting strategy.
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Affiliation(s)
- Charalampos Varlamos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Lianos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Despoina-Rafailia Benetou
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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11
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Zimarino M, Angiolillo DJ, Dangas G, Capodanno D, Barbato E, Hahn JY, Rossini R, Sibbing D, Burzotta F, Louvard Y, Shehab A, Renda G, Kimura T, Gwon HC, Chen SL, Costa R, Koo BK, Storey R, Valgimigli M, Mehran R, Stankovic G, Storey RF, Valgimigli M, Mehran R, Stankovic G. Antithrombotic therapy after percutaneous coronary intervention of bifurcation lesions. EUROINTERVENTION 2021; 17:59-66. [PMID: 32928716 PMCID: PMC9725001 DOI: 10.4244/eij-d-20-00885] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Coronary bifurcations exhibit localised turbulent flow and an enhanced propensity for atherothrombosis, platelet deposition and plaque rupture. Percutaneous coronary intervention (PCI) of bifurcation lesions is associated with an increased risk of thrombotic events. Such risk is modulated by anatomical complexity, intraprocedural factors and pharmacological therapy. There is no consensus on the appropriate PCI strategy or the optimal regimen and duration of antithrombotic treatment in order to decrease the risk of ischaemic and bleeding complications in the setting of coronary bifurcation. A uniform therapeutic approach meets a clinical need. The present initiative, promoted by the European Bifurcation Club (EBC), involves opinion leaders from Europe, America, and Asia with the aim of analysing the currently available evidence. Although mainly derived from small dedicated studies, substudies of large trials or from authors' opinions, an algorithm for the optimal management of patients undergoing bifurcation PCI, developed on the basis of clinical presentation, bleeding risk, and intraprocedural strategy, is proposed here.
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Affiliation(s)
- Marco Zimarino
- Institute of Cardiology, “G. d'Annunzio” University – Chieti, c/o Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti, Catania, and Azienda Ospedaliero Universitario “Vittorio Emanuele-Policlinico”, University of Catania, Catania, Italy
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf, and Department of Cardiology, Ludwig-Maximilians-University (LMU) München, Munich, Germany
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yves Louvard
- Ramsay Générale de Santé - Institut cardiovasculaire Paris Sud, Hopital Privé Jacques Cartier, Massy, France
| | - Abdulla Shehab
- Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Giulia Renda
- Institute of Cardiology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Shao-Liang Chen
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Ricardo Costa
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, SP, Brazil
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Robert Storey
- Cardiovascular Research Unit, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | | | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, and Medical faculty, University of Belgrade, Belgrade, Serbia
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12
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Kim DY, Cho SW, Park KT, Ahn JH, Park TK, Jang YH, Choi KH, Lee JM, Yang JH, Song YB, Choi JH, Choi SH, Gwon HC, Lee SH, Hahn JY. Long-term Outcomes of Clopidogrel Monotherapy versus Prolonged Dual Antiplatelet Therapy beyond 12 Months after Percutaneous Coronary Intervention in High-risk Patients. J Korean Med Sci 2021; 36:e106. [PMID: 33904262 PMCID: PMC8076847 DOI: 10.3346/jkms.2021.36.e106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/08/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND There are no data on comparison between clopidogrel monotherapy and prolonged dual antiplatelet therapy (DAPT) in patients at high-risk undergoing percutaneous coronary intervention (PCI). METHODS Of 2,082 consecutive patients undergoing PCI using second-generation drug-eluting stent (DES), we studied 637 patients at high-risk either angiographically or clinically who received clopidogrel longer than 24 months and were event-free at 12 months after index PCI. Patients were divided into 2 groups: the clopidogrel monotherapy group and the prolonged DAPT group. The primary outcome was a composite of all-cause death, non-fatal myocardial infarction (MI), definite or probable stent thrombosis, or stroke between 12 months and 36 months after the index PCI. RESULTS In propensity score-matched population (246 pairs), the cumulative rate of primary outcome was 4.5% in the clopidogrel monotherapy group and 4.9% in the prolonged DAPT group (hazard ratio, 1.21; 95% confidence interval, 0.54-2.75; P = 0.643). There was no significant difference in all-cause death, MI, stent thrombosis, stroke between the clopidogrel monotherapy group and the prolonged DAPT group. CONCLUSION Compared with prolonged DAPT, clopidogrel monotherapy showed similar long-term outcomes in patients at high-risk after second-generation DES implantation.
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Affiliation(s)
- Dong Yeon Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Seoul Paik Hospital, Seoul, Korea
| | - Sung Woo Cho
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Kyu Tae Park
- Division of Cardiology, Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon, Korea.
| | - Jong Hwa Ahn
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Ho Jang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Ho Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Hoon Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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13
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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] [MESH Headings] [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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14
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Alexopoulos D, Varlamos C, Benetou DR. Type and Duration of Dual Antiplatelet Therapy in Complex Percutaneous Coronary Intervention. US CARDIOLOGY REVIEW 2020. [DOI: 10.15420/usc.2020.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Complex percutaneous coronary intervention (PCI) patients are a high-risk population for ischemic complications. Antiplatelet therapy in such patients remains controversial, as the beneficial effects of more potent agents use or prolonged dual antiplatelet treatment (DAPT) on atherothrombotic complications are hindered by a concomitant increase in bleeding rates. The aim of this article is to describe ischemic and bleeding outcomes associated with complex PCI procedures and to compare different types and durations of DAPT regimens in terms of safety and efficacy outcomes. Issues concerning special patient groups, such as those with left main, chronic total occlusion, or bifurcation lesions, are discussed.
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Affiliation(s)
- Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalampos Varlamos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Despoina-Rafailia Benetou
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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15
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Cheney A, Dean LS. State-of-the-art percutaneous coronary interventions applied to the treatment of bifurcation lesions: Are we there yet? Catheter Cardiovasc Interv 2020; 96:18-19. [PMID: 32652840 DOI: 10.1002/ccd.29085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/07/2022]
Abstract
Treatment of bifurcation lesions has advanced with the development of second-generation drug-eluting stents and state-of-the-art percutaneous coronary interventions techniques. This subanalysis of SYNTAX II demonstrates similar major adverse cardiac or cerebrovascular events in patients with bifurcation and nonbifurcation lesions, with a trend toward higher target lesion failure in the bifurcation cohort. The results, while compelling, require larger studies with longer follow-up, stratified by bifurcation strategy.
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Affiliation(s)
- Amy Cheney
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Larry S Dean
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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16
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Lee OH, Kim BK, Hong SJ, Kim S, Ahn CM, Shin DH, Kim JS, Kang TS, Ko YG, Choi D, Hong MK, Jang Y. Determinants and Clinical Outcomes of Extended Dual Antiplatelet Therapy over 3 Years after Drug-Eluting Stent Implantation: A Retrospective Analysis. Yonsei Med J 2020; 61:597-605. [PMID: 32608203 PMCID: PMC7329747 DOI: 10.3349/ymj.2020.61.7.597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Although current guidelines recommend the administration of dual antiplatelet therapy (DAPT) for up to 12 months after the implantation of a drug-eluting stent (DES), extended DAPT is frequently used in real-world practice. MATERIALS AND METHODS From the Korean Multicenter Angioplasty Team registry, we identified a total of 1414 patients who used DAPT for >3 years after DES implantation (extended-DAPT group) and conducted a landmark analysis at 36 months after the index procedure. We evaluated the determinants for and long-term outcomes of extended DAPT and compared the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of all-cause death, myocardial infarction, stent thrombosis, and stroke, between the extended-DAPT group and the guideline-DAPT group [DAPT <1 year after DES implantation (n=1273)]. RESULTS Multivariate analysis indicated the occurrence of acute coronary syndrome as the most significant clinical determinant of the use of extended DAPT. Bifurcation, stent diameter ≤3.0 mm, total stented length ≥28 mm, and use of first-generation DESs were also significant angiographic and procedural determinants. MACCE rates were similar between the extended-DAPT group and the guideline-DAPT group in crude analysis [hazard ratio (HR), 1.08; 95% confidence interval (CI), 0.69-1.68; p=0.739] and after propensity matching (HR, 1.22; 95% CI, 0.72-2.07; p=0.453). Major bleeding rates were comparable between the two groups. CONCLUSION In patients undergoing percutaneous coronary intervention, indefinite use of DAPT does not show superior outcomes to those of guideline-DAPT. Major bleeding rates are also similar.
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Affiliation(s)
- Oh Hyun Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea
| | - Byeong Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Sung Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seunghwan Kim
- Division of Cardiology, Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Chul Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ho Shin
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Soo Kang
- Division of Cardiovascular Medicine, Department of Internal Medicine, Dankook University Hospital, Dankook University School of Medicine, Cheonan, Korea
| | - Young Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea
| | - Myeong Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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17
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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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18
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Abstract
Dual antiplatelet therapy (DAPT) duration in patients undergoing percutaneous coronary intervention (PCI) has long been considered a matter of controversy. Complex-PCI (C-PCI) is considered to be associated with an increased ischemic risk that tends to be greater with progressively higher procedural complexity. Thus, with a view to balance ischemic versus bleeding risks, high complexity of PCI intuitively represents an advocate of prolonged DAPT duration. However, the optimal DAPT strategy in this high ischemic risk subset of patients remains unclear, a fact that is exacerbated by the absence of a universal definition of C-PCI, resulting in a significant between-study heterogeneity. The aim of this review is to highlight the increased risks associated with C-PCI, compare long- versus short-term DAPT regimens regarding safety and efficacy endpoints as well as investigate outcomes in special C-PCI cohorts, such as patients with bifurcation, left main or chronic total occlusion lesions. Furthermore, controversial issues, such as antithrombotic regimens in C-PCI patients with atrial fibrillation, and future perspectives are addressed.
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19
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D'Ascenzo F, Barbero U, Abdirashid M, Trabattoni D, Boccuzzi G, Ryan N, Quadri G, Capodanno D, Venuti G, Muscoli S, Tomassini F, Autelli M, Montabone A, Wojakowski W, Rognoni A, Gallo D, Parma R, De Luca L, Figini F, Mitomo S, Montefusco A, Mattesini A, Wańha W, Protasiewicz M, Smolka G, Huczek Z, Rolfo C, Cortese B, Chieffo A, Kuliczowki W, Nuñez-Gil I, Morbiducci U, Ugo F, Marengo G, Iannaccone M, Cerrato E, Mario CD, Moretti C, D'Amico M, Varbella F, Lüscher TF, Sheiban I, Escaned J, Romeo F, Rinaldi M, De Ferrari GM, Helft G. Incidence of Adverse Events at 3 Months Versus at 12 Months After Dual Antiplatelet Therapy Cessation in Patients Treated With Thin Stents With Unprotected Left Main or Coronary Bifurcations. Am J Cardiol 2020; 125:491-499. [PMID: 31889527 DOI: 10.1016/j.amjcard.2019.10.058] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 11/29/2022]
Abstract
Incidence and predictors of adverse events after dual antiplatelet therapy (DAPT) cessation in patients treated with thin stents (<100 microns) in unprotected left main (ULM) or coronary bifurcation remain undefined. All consecutive patients presenting with a critical lesion of an ULM or involving a main coronary bifurcation who were treated with very thin strut stents were included. MACE (a composite end point of cardiovascular death, myocardial infarction [MI], target lesion revascularization [TLR], and stent thrombosis [ST]) was the primary endpoint, whereas target vessel revascularization (TVR) was the secondary endpoint, with particular attention to type and occurrence of ST and occurrence of ST, CV death, and MI during DAPT or after DAPT discontinuation. All analyses were performed according to length of DAPT dividing the patients in 3 groups: Short DAPT (3-months), intermediate DAPT (3 to 12 months), and long DAPT (12-months). A total of 117 patients were discharged with an indication for DAPT ≤3 months (median 1: 1 to 2.5), 200 for DAPT between 3 and 12 months (median 8: 7 to 10), and 1,958 with 12 months DAPT. After 12.8 months (8 to 20), MACE was significantly higher in the 3-month group compared with 3 to 12 and 12-month groups (9.4% vs 4.0% vs 7.2%, p ≤0.001), mainly driven by MI (4.4% vs 1.5% vs 3%, p ≤0.001) and overall ST (4.3% vs 1.5% vs 1.8%, p ≤0.001). Independent predictors of MACE were low GFR and a 2 stent strategy. Independent predictors of ST were DAPT duration <3 months and the use of a 2-stent strategy. In conclusion, even stents with very thin strut when implanted in real-life ULM or coronary bifurcation patients discharged with short DAPT have a relevant risk of ST, which remains high although not significant after DAPT cessation.
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Affiliation(s)
- 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 Cardioloy, Universityspirtal of Zürich, Zürich, Switzerland
| | - Umberto Barbero
- Ospedale Civile SS. Annunziata, Savigliano, Italiy, Via Ospedali, 9, 12038
| | - Mohamed Abdirashid
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy.
| | - Daniela Trabattoni
- Department of Cardiovascular Sciences, IRCCS Centro Cardiologico Monzino, Milan, Italy; University of Milan, Milan, Italy
| | | | - Nicola Ryan
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Giorgio Quadri
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele," Catania, Italy
| | - Giuseppe Venuti
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele," Catania, Italy
| | - Saverio Muscoli
- San Raffaele Scientific Institute, Milan, Italy; Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | - Francesco Tomassini
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Michele Autelli
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Andrea Montabone
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | | | - Andrea Rognoni
- Coronary Care Unit and Catheterization laboratory, A.O.U. Maggiore della Carità, Novara, Italy
| | - Diego Gallo
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, and Royal Brompton and Harefield Hospital Trust and Imperial College, London, United Kingdom
| | | | - Leonardo De Luca
- Division of Cardiology, S. Giovanni Evangelista Hospital, Tivoli, Italy
| | | | - Satoru Mitomo
- San Raffaele Scientific Institute, Milan, Italy; Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | - Antonio Montefusco
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Alessio Mattesini
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Wojciech Wańha
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Marcin Protasiewicz
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Grzegorz Smolka
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Cristina Rolfo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Bernardo Cortese
- Interventional Cardiology, ASST Fatebenefratelli-Sacco, Milano, Italy
| | | | - Wiktor Kuliczowki
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Ivan Nuñez-Gil
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Umberto Morbiducci
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, and Royal Brompton and Harefield Hospital Trust and Imperial College, London, United Kingdom
| | - Fabrizio Ugo
- Dipartimento di Cardiologia, Ospedale San Giovanni Bosco, Italy
| | - Giorgio Marengo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Mario Iannaccone
- Ospedale Civile SS. Annunziata, Savigliano, Italiy, Via Ospedali, 9, 12038
| | - Enrico Cerrato
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Carlo di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Claudio Moretti
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Maurizio D'Amico
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Ferdinando Varbella
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Thomas F Lüscher
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | | | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Francesco Romeo
- Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | - Mauro Rinaldi
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Gerard Helft
- Pierre and Marie Curie University, Paris, France
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20
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Saito Y, Kobayashi Y. Update on Antithrombotic Therapy after Percutaneous Coronary Intervention. Intern Med 2020; 59:311-321. [PMID: 31588089 PMCID: PMC7028427 DOI: 10.2169/internalmedicine.3685-19] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 08/26/2019] [Indexed: 02/06/2023] Open
Abstract
Percutaneous coronary intervention (PCI) has become a standard-of-care procedure in the setting of angina or acute coronary syndrome. Antithrombotic therapy is the cornerstone of pharmacological treatment aimed at preventing ischemic events following PCI. Dual antiplatelet therapy as the combination of aspirin and P2Y12 inhibitor has been proven to decrease stent-related thrombotic risks. However, the optimal duration of dual antiplatelet therapy, an appropriate P2Y12 inhibitor, and the choice of aspirin versus P2Y12 inhibitor as single antiplatelet therapy remain controversial. Furthermore, the combined use of oral anticoagulation in addition to antiplatelet therapy is a complex issue in clinical practice, such as in patients with atrial fibrillation. The key challenge concerning the optimal antithrombotic regimen is ensuring a balance between protection against thrombotic events and against excessive increases in bleeding risk. In this review article, we summarize the current evidence concerning antithrombotic therapy in patients with coronary artery disease undergoing PCI.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
- Yale School of Medicine, USA
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
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21
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Cho S, Kim JS, Kang TS, Hong SJ, Shin DH, Ahn CM, Kim BK, Ko YG, Choi D, Song YB, Hahn JY, Choi SH, Gwon HC, Hong MK, Jang Y. Long-Term Efficacy of Extended Dual Antiplatelet Therapy After Left Main Coronary Artery Bifurcation Stenting. Am J Cardiol 2020; 125:320-327. [PMID: 31780076 DOI: 10.1016/j.amjcard.2019.10.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 10/21/2019] [Accepted: 10/28/2019] [Indexed: 12/13/2022]
Abstract
Limited data exist on the long-term efficacy of extended dual antiplatelet therapy (DAPT) after left main coronary artery (LMCA) bifurcation stenting. This study investigated the long-term clinical outcomes associated with long-term DAPT after LMCA bifurcation stenting. Using data from the multicenter KOMATE and COBIS registries, we analyzed 1,142 patients who received a drug-eluting stent for a LMCA bifurcation lesion and who experienced no adverse events for 12 months after the index procedure. Patients were divided into 2 groups: DAPT >12 months (n = 769) and DAPT ≤12 months (n = 373). The primary end point was major adverse cardiovascular events (MACEs), as a composite of cardiac death, myocardial infarction, stroke, and stent thrombosis, over 5 years of follow-up. We further performed propensity score adjustment for clinical outcomes. DAPT >12 months afforded a lower MACE rate than DAPT ≤12 months (2.3% vs 5.4%, adjusted hazard ratio [HR] 0.37; 95% confidence interval [CI] 0.19 to 0.71; p = 0.003). The use of DAPT for >12 months was an independent predictor of a reduced likelihood of MACEs (HR 0.34; 95% CI 0.17 to 0.67; p = 0.002). A DAPT score ≥2, chronic kidney disease, and age >75 years were significant independent predictors of MACEs. In subgroup analysis, the use of DAPT for >12 months consistently resulted in better clinical outcomes across all subgroups, especially among patients with ACS, compared with the use of DAPT for ≤12 months. In conclusion, an extended duration of DAPT reduces MACE rates after LMCA bifurcation stenting.
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22
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Clinical benefits of prolonged dual antiplatelet therapy following complex percutaneous coronary intervention. Coron Artery Dis 2019; 31:273-278. [PMID: 31658148 DOI: 10.1097/mca.0000000000000827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS Prolonged dual antiplatelet therapy (DAPT) requires consideration of both reduced thrombotic events and increased bleeding risk. The associated subtle balance between the benefits and harms depends upon patient's clinical factors and complexity of the coronary anatomy. Our aim was to assess the safety and efficacy of prolonged (>12 months) DAPT in patients undergoing complex percutaneous coronary intervention (PCI). METHODS AND RESULTS A thorough computer-based search was performed using four major databases. Complex PCI was defined as a procedure with at least one of the following angiographic characteristics: 3 vessels treated, >3 stents implanted, >3 lesions treated, bifurcation lesions, total stent length >60 mm, left main or proximal left anterior descending, a vein graft stent, or chronic total occlusion as target lesion. Of the 3543 titles searched, 5 studies met the inclusion criteria comparing short and prolonged DAPT therapy. We applied a random-effects model to acknowledge the variation in study design, treatment duration, and length of follow-up among studies. There was a reduction in cardiac mortality [odds ratio (OR) 0.57, 95% confidence interval (CI): 0.35-0.92; P = 0.02, I = 0%] and major adverse cardiovascular events (OR 0.76, 95% CI: 0.59-0.96; P = 0.02, I = 22%) with prolonged DAPT. Major bleeding was increased with prolonged DAPT (OR 1.75, 95% CI: 1.20-2.20; P = 0.004, I = 0%). There was no difference in the all-cause mortality (OR 0.86, 95% CI: 0.61-1.22; P = 0.41, I = 0%). CONCLUSION Prolonged DAPT reduces cardiac mortality and major adverse cardiovascular events in complex PCI. The results would need confirmation in a larger randomized study.
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23
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[Optimal duration of dual antiplatelet therapy after coronary stent placement or acute coronary syndrome. Is customisation possible?]. Ann Cardiol Angeiol (Paris) 2019; 68:347-357. [PMID: 31471043 DOI: 10.1016/j.ancard.2019.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/22/2019] [Indexed: 11/20/2022]
Abstract
The recommended 6-month dual antiplatelet therapy (DAPT) after coronary angioplasty with implantation of a drug eluting stent is based on solid evidence, but must take into account continuous improvements in stent technology leading to reduced thrombogenicity. In stable patients with a high hemorrhagic risk, it is possible to reduce DAPT duration at 3 months without significant increase in the risks of ischemic events or stent thrombosis. Further reduction toward a 1-month DAPT is likely to involve new strategies of stopping aspirin at 1 month, and continuing long-term monotherapy with inhibitors of P2Y12 receptor. After acute coronary syndrome, it seems possible to reduce the duration of DAPT (standard, 12 months) in patients at high risk of bleeding. A 6-month DAPT, or even less, provides a good compromise between hemorrhagic risk and ischemic recurrences. Conversely, in patients who have fully tolerated a 12-month DAPT after infarction, and who are at very high risk of ischemic recurrence, the prolongation of a P2Y12 inhibitor in combination with aspirin may be considered, with a risk of haemorrhage almost double. A certain degree of customisation of the duration of DAPT is therefore possible, based on age, renal function, comorbidities, haemorrhagic history, and the use of risk scores (PRECISE-DAPT, DAPT).
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24
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Kogame N, Chichareon P, De Wilder K, Takahashi K, Modolo R, Chang CC, Tomaniak M, Komiyama H, Chieffo A, Colombo A, Garg S, Louvard Y, Jüni P, G. Steg P, Hamm C, Vranckx P, Valgimigli M, Windecker S, Stoll H, Onuma Y, Janssens L, Serruys PW. Clinical relevance of ticagrelor monotherapy following 1‐month dual antiplatelet therapy after bifurcation percutaneous coronary intervention: Insight from GLOBAL LEADERS trial. Catheter Cardiovasc Interv 2019; 96:100-111. [DOI: 10.1002/ccd.28428] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/10/2019] [Accepted: 07/27/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Norihiro Kogame
- Department of CardiologyAmsterdam University Medical Center Amsterdam The Netherlands
- Department of CardiologyToho University medical center Ohashi hospital Tokyo Japan
| | - Ply Chichareon
- Department of CardiologyAmsterdam University Medical Center Amsterdam The Netherlands
- Faculty of Medicine, Division of Cardiology, Department of Internal MedicinePrince of Songkla University Songkhla Thailand
| | | | - Kuniaki Takahashi
- Department of CardiologyAmsterdam University Medical Center Amsterdam The Netherlands
| | - Rodrigo Modolo
- Department of CardiologyAmsterdam University Medical Center Amsterdam The Netherlands
- Cardiology Division, Department of Internal MedicineUniversity of Campinas (UNICAMP) Campinas Brazil
| | - Chun Chin Chang
- Department of Interventional CardiologyThoraxcenter, Erasmus Medical Center Rotterdam The Netherlands
| | - Mariusz Tomaniak
- Department of Interventional CardiologyThoraxcenter, Erasmus Medical Center Rotterdam The Netherlands
| | - Hidenori Komiyama
- Department of CardiologyAmsterdam University Medical Center Amsterdam The Netherlands
| | - Alaide Chieffo
- Interventional Cardiology UnitIRCCS San Raffaele Scientific Institute Milan Italy
| | - Antonio Colombo
- Interventional Cardiology UnitVilla Maria Cecila Hospital GVM Cotignola (RA) Italy
| | - Scot Garg
- Department of CardiologyRoyal Blackburn Hospital Blackburn UK
| | - Yves Louvard
- Department of CardiologyRamsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Hopital Privé Jacques Cartier Massy France
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital Toronto Ontario Canada
- Department of Medicine and Institute of Health Policy, Management and EvaluationUniversity of Toronto Toronto Ontario Canada
| | - Philippe G. Steg
- French Alliance for Cardiovascular Trials (FACT), Université Paris‐Diderot Paris France
| | - Christian Hamm
- Kerckhoff Heart and Thorax Center, University of Giessen Giessen Germany
| | - Pascal Vranckx
- Faculty of Medicine and Life Sciences, Jessa Ziekenhuis, the Hasselt University Hasselt Belgium
| | - Marco Valgimigli
- Department of CardiologyInselspital, University of Bern Bern Switzerland
| | - Stephan Windecker
- Department of CardiologyInselspital, University of Bern Bern Switzerland
| | | | - Yoshinobu Onuma
- Department of Interventional CardiologyThoraxcenter, Erasmus Medical Center Rotterdam The Netherlands
| | - Luc Janssens
- Heart CentreImelda Hospital Bonheiden Bonheiden Belgium
| | - Patrick W. Serruys
- International Centre for Circulatory Health, Imperial College London London UK
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25
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Banning AP, Lassen JF, Burzotta F, Lefèvre T, Darremont O, Hildick-Smith D, Louvard Y, Stankovic G. Percutaneous coronary intervention for obstructive bifurcation lesions: the 14th consensus document from the European Bifurcation Club. EUROINTERVENTION 2019; 15:90-98. [PMID: 31105066 DOI: 10.4244/eij-d-19-00144] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The European Bifurcation Club recommends an approach to a bifurcation stenosis which involves careful assessment, planning and a sequential provisional approach. In the minority of lesions where two stents are required, careful deployment and optimal expansion are essential to achieve a long-term result.
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Affiliation(s)
- Adrian P Banning
- Department of Cardiology, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
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26
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Rhee TM, Park KW, Kim HS. Reply: Duration of Dual-Antiplatelet Therapy After Left Main Stenting: Progressive Steps Towards the Correct Answer. JACC Cardiovasc Interv 2019; 12:690-691. [PMID: 30947944 DOI: 10.1016/j.jcin.2019.01.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 11/26/2022]
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27
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Ando T, Aoi S, Ashraf S, Villablanca PA, Telila T, Briasoulis A, Takagi H, Afonso L, Grines CL. Transradial versus transfemoral percutaneous coronary intervention of left main disease: A systematic review and meta‐analysis of observational studies. Catheter Cardiovasc Interv 2018; 94:264-273. [DOI: 10.1002/ccd.28025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/11/2018] [Accepted: 11/25/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Tomo Ando
- Department of Medicine Division of CardiologyWayne State University/Detroit Medical Center Detroit Michigan
- ALICE (All‐Literature Investigation of Cardiovascular Evidence) Group
| | - Shunsuke Aoi
- Department of Medicine Division of CardiologyMount Sinai Beth Israel, Icahn School of Medicine New York New York
| | - Said Ashraf
- Department of Medicine Division of CardiologyWayne State University/Detroit Medical Center Detroit Michigan
| | - Pedro A. Villablanca
- Department of Medicine, Division of CardiologyHenry Ford Hospital Detroit Michigan
| | | | - Alexandros Briasoulis
- Department of Medicine, Division of Cardiovascular MedicineUniversity of Iowa Hospitals and Clinics Iowa Iowa
| | - Hisato Takagi
- ALICE (All‐Literature Investigation of Cardiovascular Evidence) Group
- Department of Medicine, Division of Cardiovascular Surgery, Shizuoka Medical Center Shizuoka Japan
| | - Luis Afonso
- Department of Medicine Division of CardiologyWayne State University/Detroit Medical Center Detroit Michigan
| | - Cindy L. Grines
- Department of Medicine Division of CardiologyNorth Shore University Hospital, Hofstra Northwell School of Medicine New York
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28
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Horowitz JD, Sage PR. Can We Improve Long-Term Outcomes Postbifurcation Stenting by Prolonged Dual Antiplatelet Therapy? Circ Cardiovasc Interv 2018; 11:e006922. [DOI: 10.1161/circinterventions.118.006922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John D. Horowitz
- Cardiology Unit, Queen Elizabeth Hospital, University of Adelaide, Australia
| | - Peter R. Sage
- Cardiology Unit, Queen Elizabeth Hospital, University of Adelaide, Australia
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