Long-Term Safety and Efficacy of Extended Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation in Real-World Practice

Multiple genetic mutations increase the risk of thrombosis associated with clopidogrel after percutaneous coronary intervention

Background: The effect of multiple mutations in CYP2C19, PON1 and ABCB1 genes on the effectiveness and safety of dual antiplatelet therapy after percutaneous coronary intervention remains unclear. Methods: In total, 263 Chinese Han patients were enrolled in this study. Platelet aggregation rates and thrombosis risk were used to compare clopidogrel responses and outcomes in patients with different numbers of genetic mutations. Results: Our study demonstrated that 74% of the patients carried more than two genetic mutations. High platelet aggregation rates were associated with genetic mutations in patients receiving clopidogrel and aspirin after percutaneous coronary intervention. Genetic mutations were closely related to the recurrence of thrombotic events, but not bleeding. The number of genes that become dysfunctional in patients is directly correlated with the risk of recurrent thrombosis. Conclusion: Compared with CYP2C19 alone or the platelet aggregation rate, it is more helpful to predict clinical outcomes by considering the polymorphisms of all three genes.

Duration and clinical outcomes of dual antiplatelet therapy following percutaneous coronary intervention for acute coronary syndrome: A multicentre "real-world practice" registry-based study

Background

The optimal duration of dual antiplatelet therapy (DAPT) ought to be determined taking into account individual ischaemic or bleeding events risks. To date, studies have provided inconclusive evidence on the effects of prolonged DAPT. We sought to evaluate the long-term outcomes of this strategy following percutaneous revascularization in the context of acute coronary syndrome (ACS).

Methods

Retrospectively from four centers in Madrid, we identified 750 consecutive ACS patients, divided in two groups of DAPT duration: <13 months and >13 months, with a mean follow-up of 48 months.

Results

Patients with DAPT > 13 months had a higher non-adjusted incidence of Major Adverse Cardiovascular Events (11.6% vs. 17.3%) and new revascularization (3.7% vs. 8.7%). Differences in all-cause death, cardiac death, myocardial infarction, stent thrombosis and stroke were non-significant. There was no difference in the incidence of major bleeding (7.4% vs. 6.3%). Multivariable Cox regression analysis showed that the independent risk predictors of MACE were age (HR: 1.04, 95% CI: 1.02-1.06, p < 0.001) and multivessel disease (HR: 2.29, 95% CI: 1.32-3.95, p = 0.003), whereas the independent protective predictor was normal hemoglobin (HR: 0.88, 95% CI: 0.78-0.98, p = 0.022).

Conclusions

In this real-world registry cohort of ACS patients treated with PCI and 1 year of DAPT in Spain, we report a trend of increased rate of MACE and new revascularization not associated with TVR in patients with longer DAPT. Our findings support the need for future randomized controlled trials to confirm or refute these results.

Is the duration of dual antiplatelet therapy (DAPT) excessive in post-angioplasty in chronic coronary syndrome? Data from the France-PCI registry (2014-2019)

Background

while the duration of dual antiplatelet therapy (DAPT) following coronary angioplasty for chronic coronary syndrome (CCS) recommended by the European Society of Cardiology has decreased over the last decade, little is known about the adherence to those guidelines in clinical practice in France.

Aim

To analyze the real duration of DAPT post coronary angioplasty in CCS, as well as the factors affecting this duration.

Methods

Between 2014 and 2019, 8.836 percutaneous coronary interventions for CCS from the France-PCI registry were evaluated, with 1 year follow up, after exclusion of patients receiving oral anticoagulants, procedures performed within one year of an acute coronary syndrome, and repeat angioplasty.

Results

Post-percutaneous coronary intervention (PCI) DAPT duration was > 12 months for 53.1% of patients treated for CCS; 30.5% had a DAPT between 7 and 12 months, and 16.4% a DAPT ≤ 6 months. Patients with L-DAPT (>12 months) were at higher ischemic risk [25.0% of DAPT score ≥2 vs. 18.8% DAPT score ≥2 in S&I-DAPT group (≤12 months)]. The most commonly used P2Y12 inhibitor was clopidogrel (82.2%). The prescription of ticagrelor increased over the period.

Conclusions

post-PCI DAPT duration in CCS was higher than international recommendations in the France PCI registry between 2014 and 2019. More than half of the angioplasty performed for CCS are followed by a DAPT > 12 months. Ischemic risk assessment influences the duration of DAPT. This risk is probably overestimated nowadays, leading to a prolongation of DAPT beyond the recommended durations, thus increasing the bleeding risk.

Long-Term Safety and Efficacy of Prolonged Dual Antiplatelet Therapy according to Baseline Anemia after Percutaneous Coronary Intervention

PURPOSE

We aimed to evaluate the outcomes of prolonged dual antiplatelet therapy (DAPT) depending on baseline anemia after percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

Among the 1470 study participants, 448 (30.5%) were classified as having baseline anemia. We categorized the study population according to baseline anemia and DAPT duration: ≤12-month (m) DAPT (n=226) vs. >12-m DAPT (n=222) in anemic patients, and ≤12-m DAPT (n=521) vs. >12-m DAPT (n=501) in non-anemic patients.

RESULTS

During a follow-up of 80.8 (interquartile range 60.6-97.1) months, anemic patients showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) (26.9% vs. 17.1%, p<0.001) and major bleeding (9.8% vs. 5.1%, p=0.006). Among the non-anemic patients, prolonged DAPT was associated with a reduced rate of MACCEs [inverse probability of treatment weighting (IPTW) adjusted hazard ratio (HR), 0.78; 95% confidence interval (CI), 0.63-0.96; p=0.019] without an increase in major bleeding (IPTW adjusted HR, 1.12; 95% CI, 0.75-1.68; p=0.574). However, prolonged DAPT was not related to the incidence of MACCEs (IPTW adjusted HR, 1.11; 95% CI, 0.88-1.39; p=0.387), with increased major bleeding (IPTW adjusted HR, 2.01; 95% CI, 1.32-3.06; p=0.001) among anemic patients.

CONCLUSION

Although extended DAPT led to a reduction in MACCEs in non-anemic patients, it was related to increased major bleeding without reducing MACCEs in anemic patients.