Antiplatelet strategies for complex PCI

Recent Advances in Antiplatelet Therapy in Complex Percutaneous Coronary Intervention

Antithrombotic therapy is the cornerstone of secondary cardiovascular prevention after percutaneous coronary intervention (PCI). Improvements in drug-eluting stent (DES) design and materials over the last 2 decades have prompted the development of new antithrombotic strategies. Current guidelines recommend to tailor dual antiplatelet therapy (DAPT) according to clinical presentation and individual ischemic and bleeding risk. Given the growing number of complex PCI procedures performed nowadays, it is a priority to define the optimal antithrombotic treatment in this challenging patient subset. In this review article, we sought to summarize and discuss the current evidence on antiplatelet therapy in patients undergoing complex PCI.

Periprocedural Antithrombotic Treatment in Complex Percutaneous Coronary Intervention

ABSTRACT

In recent years, the management of complex lesions in patients undergoing percutaneous coronary intervention (PCI) constitutes a field of high interest and concern for the interventional cardiology. As more and more studies demonstrate the increased hazard of ischemic events in this group of patients, it is of paramount importance for the physicians to choose the optimal periprocedural (pre-PCI, during-PCI and post-PCI) antithrombotic treatment strategies wisely. Evidence regarding the safety and efficacy of current anticoagulation recommendation, the possible beneficial role of the pretreatment with a potent P2Y12 inhibitor in the subgroup of patients with non-ST segment elevation myocardial infarction with complex lesions, and the impact of a more potent P2Y12 inhibitor in individuals with stable coronary artery disease undergoing complex PCI are needed. This will provide and serve as a guide to clinicians to deploy the maximum efficacy of the current choices of antithrombotic therapy, which will lead to an optimal balance between safety and efficacy in this demanding clinical scenario.

Prognostic and Practical Validation of ESC/EACTS High Ischemic Risk Definition on Long-Term Thrombotic and Bleeding Events in Contemporary PCI Patients

Aims: The ESC/EACTS myocardial revascularization guidelines recently standardized the definition of patients at high ischemic risk (HIR). However, the ability of ESC/EACTS–HIR criteria to stratify ischemic and bleeding risk in a contemporary real-world East Asian cohort remains unexplored.

Methods: A total of 10,167 consecutive patients undergoing PCI from prospective Fuwai PCI Registry (January 2013 to December 2013) were reviewed. ESC/EACTS–HIR features was defined as having at least one of the eight clinical and angiographic characteristics. The primary ischemic endpoint was target vessel failure (cardiac death, target vessel myocardial infarction [MI], or target vessel revascularization [TVR]); bleeding outcome was assessed using the BARC type 2, 3, or 5 bleeding. Median follow-up was 29 months.

Results: Compared with non-HIR patients, HIR patients ( n =5,149, 50.6%) were associated with increased risk for target vessel failure (adjusted hazard ratio [HR _adjust ]: 1.48 [1.25–1.74]) and patient-oriented composite outcome (HR _adjust : 1.44 [1.28–1.63]), as well as cardiac death, MI, and TVR. By contrast, the risk of clinically relevant bleeding was not significantly different between the two groups. (HR _adjust : 0.84 [0.66–1.06]). Greater than or equal to three implanted stents and diabetic patients with diffuse multivessel coronary disease emerged as independent predictors for long-term adverse outcomes. There was no significant interaction between high bleeding risk (HBR) status and clinical outcomes associated with ESC/EACTS–HIR criteria (all P _interaction ＞0.05).

Conclusion: The ESC/EACTS–HIR features identified patients at increased risk of thrombotic events, including cardiac death, but not for clinically relevant bleeding. Importantly, HBR did not modify cardiovascular risk subsequent to patients with ESC/EACTS–HIR features, suggesting its potential clinical applicability in tailoring antithrombotic therapy.