6- Versus 24-Month Dual Antiplatelet Therapy After Implantation of Drug-Eluting Stents in Patients Nonresistant to Aspirin: Final Results of the ITALIC Trial (Is There a Life for DES After Discontinuation of Clopidogrel)

OBJECTIVES

The aim of this study was to test the hypothesis that 6-month dual antiplatelet therapy (DAPT) is noninferior to 24-month DAPT in aspirin-sensitive patients.

BACKGROUND

The ITALIC (Is There a Life for DES After Discontinuation of Clopidogrel) trial showed that rates of bleeding and thrombotic events at 1 year were much the same with 6 versus 12 months of DAPT after percutaneous coronary intervention with second-generation drug-eluting stents. In this report, 2-year follow-up is presented.

METHODS

In a multicenter randomized study, patients with confirmed nonresistance to aspirin undergoing drug-eluting stent implantation were allocated to 6 or 24 months of DAPT. The primary endpoint was a composite of death, myocardial infarction, urgent target vessel revascularization, stroke, and major bleeding at 12 months post-percutaneous coronary intervention. The secondary endpoints comprised the same composite endpoint at 24 months and each individual component.

RESULTS

Overall, 2,031 patients from 70 centers were screened; 926 were randomized to 6-month and 924 to 24-month DAPT. Noninferiority was demonstrated for 6- versus 12-month DAPT, with an absolute risk difference of 0.11% (95% confidence interval: -1.04% to 1.26%; p = 0.0002). At 2 years, the composite endpoint was unchanged, at 3.5% for 6 months and 3.7% for 24 months (p = 0.79), and rates of myocardial infarction (1.3% vs. 1.0%; p = 0.51), stroke (0.6% vs. 0.8%; p = 0.77), and target vessel revascularization (1.0% vs. 0.3%; p = 0.09) were likewise similar. There was a trend toward higher mortality with longer DAPT (2.2% vs. 1.2%; p = 0.11). Four patients (0.4%) in the 24-month group and none in the 6-month group had major bleeding.

CONCLUSIONS

Two-year outcomes in the ITALIC trial confirmed the 1-year results and showed that patients receiving 6-month DAPT after percutaneous coronary intervention with second-generation drug-eluting stent have similar outcomes to those receiving 24-month DAPT.

Incidence of acute pulmonary embolism in a general hospital: relation to age, sex, and race

PURPOSE

The purpose of this investigation is to determine the incidence of acute pulmonary embolism (PE) according to age, sex, and race in a tertiary care general hospital.

BACKGROUND

Population-based investigations and autopsy studies have shown that acute PE occurs predominantly in middle-aged and elderly people. The incidence of PE according to age, race, and sex in a general hospital has been only sparsely studied.

METHODS

Patients with PE diagnosed by a high-probability ventilation/perfusion lung scan or pulmonary angiography were identified in a tertiary care general hospital. The incidence of PE was determined according to age, sex, and race.

RESULTS

The incidence of PE was 400 of 175,730 (0.23%; 95% CI, 0.21 to 0.25%). The incidence was linearly related to age (r = 0.94). Among patients >/= 50 years of age, the incidence of PE was higher among women (0.40% vs 0.29%; p < 0.01). The incidence was comparable among patients < 50 years of age. African Americans showed an incidence of 0.26%, and whites showed an incidence of 0. 21% (p < 0.05).

CONCLUSION

Acute PE in a tertiary care hospital is more frequent than previously reported among short-term hospitals. Occasionally, young adults and adolescents had PE, although PE occurred primarily among middle-aged and elderly patients. Among patients >/= 50 years of age, the incidence of PE was higher among women. The incidence was not higher among women < 50 years of age, suggesting that childbirth and birth control pills had little impact. Only a trivial difference of the incidence of PE was observed among African Americans compared to whites.

Leukocytosis in acute pulmonary embolism

PURPOSE

The purpose of this investigation is to assess the level of leukocytosis in acute pulmonary embolism (PE).

BACKGROUND

Limited data exist regarding leukocytosis in acute PE. One reason that the prevalence of leukocytosis in acute PE is unknown, despite an extensive number of investigations of PE, may relate to the fact that acute PE is usually associated with other conditions that themselves may cause leukocytosis.

METHODS

Hospital records of 386 patients with a diagnosis of acute PE were reviewed retrospectively. Patients with no other possible or definite cause of leukocytosis were analyzed separately. A diagnosis of PE was made by a high-probability interpretation of the ventilation/perfusion lung scan or pulmonary angiogram.

RESULTS

Among patients with PE in whom other possible or defined causes for leukocytosis were eliminated, 52 of 266 (20%) had a WBC count > 10,000/mm3. None had a WBC count that was > or = 20,000/mm3. Patients with the pulmonary hemorrhage/infarction syndrome had an increased WBC count in 32 of 183 (17%) vs 20 of 83 (24%) in patients who did not have pulmonary hemorrhage/infarction syndrome (not significant).

CONCLUSION

A modest leukocytosis may accompany (and possibly be caused by) PE. Its presence should not dissuade the clinician from objectively pursuing the diagnosis of PE.