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.

P823Clinical benefits of high dose statins according to the atherothrombotic risk stratification after acute myocardial infarction. The FAST-MI registries

Background

High dose statins prescription are strongly recommended in patients after acute myocardial infarction (AMI) in current guidelines.

Aim

We aimed to assess the clinical impact on major cardiovascular events (MACE) of high dose statins prescription at discharge according to the atherothrombotic risk stratification in a routine-practice population of AMI patients, and to determine the relative efficacy of currently recommended high dose statins according to risk level.

Methods

We used data from the 2005, and 2010 FAST-MI nationwide registries, including 7,839 patients with AMI (54% STEMI) admitted to cardiac intensive care units in France. Atherothrombotic risk stratification was performed using the TIMI Risk Score for Secondary Prevention (TRS-2P). Patients were defined in 3 categories: Group 1 (Low-risk; TRS-2P=0/1); Group 2 (Intermediate-risk; TRS-2P=2); and, Group 3 (High-risk; TRS-2P≥3). Baseline characteristics and the rate of MACE (defined as death, stroke or re-MI) at 5-years were analyzed according to TRS-2P categories, and the impact of high dose statins (i.e. atorvastatin 80mg/day or rosuvastatin 20mg/day) at discharge was compared using Cox multivariate analysis among the different risk groups.

Results

A total of 7,348 patients discharge alive and in whom TRS-2P was available. Prevalence of Groups 1, 2, and Group 3 was 41.5%, 25% and 33.5% respectively. Over the 5-year period, the overall risk of patients admitted for AMI decreased in Group 3 from 41% to 27% (P<0.001). Optimal medical therapy at discharge (defined by the use of dual antiplatelets therapy, statins for all; and, beta-blocker, ACE-I or ARB when appropriate) was 53% in Group 3, 67% in Group 2, and 80% in Group 1 (P<0.001). High dose statins prescription at discharge was 18.5% (Group 3), 31.3% (Group 2), and 41.3%% (Group 1). High dose statins prescription was associated with lower MACE at five-year in the overall population compared to patients with intermediate/low dose statins or without statin prescription (14.3% vs. 29.6%; Δ absolute risk= 15.3%; HR adjusted on baseline characteristics and management: 0.86, 0.76–0.97, P=0.018). The decrease in MACE at five-year was observed in all TRS-2P categories (Group 1: 8.1% vs. 10.7%, Δ= 2.6%; Group 2: 14.8% vs. 21.6%, Δ= 6.8%; Group 3: 30.8% vs. 51.6%, Δ= 20.8%). Finally, the benefits of high dose statins in low- and intermediate-risk was lower (HR=0.97; 95% CI, 0.74–1.26; P=0.81 and HR=1.06; 95% CI, 0.81–1.38; P=0.81) compared to high-risk patients (HR=0.78; 95% CI, 0.65–0.94; P=0.008).

Five-year events-free survival

Conclusions

High dose statins prescription at discharge after AMI was associated with lower MACE at five-year regardless of the atherothrombotic risk stratification, although the highest absolute reduction was found in the high risk TRS2P class.

Acknowledgement/Funding

The FAST-MI 2010 registry is a registry of the French Society of Cardiology, supported by unrestricted grants from: Merck, the Eli-Lilly-Daiichi-Sanky

[Premedication by thienopyridine before percutaneous coronary interventions in unstable angina]

Ticlopidine or clopidogrel combined with aspirin decrease major cardiac events (Mace) after PTCA with stent implantation. It has not be proven yet that pretreatment by T or C was superior to conventional post-treatment, especially in unstable patients. The aim of the present study was to determine the influence of thienopyridine pretreatment on the risk of Mace (death, Q wave myocardial infarction, need for repeat PTCA or surgery, angina recurrence, stent thrombosis) during the hospitalization period in a population prospectively included in 2 multicentre registries of patients undergoing placement of a S670 or S7 stent (Medtronic) implanted in native coronary arteries (> or = 3.0 mm). Among the 2929 patients included into the registries, 1205 had unstable angina (41%). 50.2% of the patients were pretreated by T or C (T = 15.7%, C = 34.5%); 85.5% received aspirin before the procedure; definition of pretreatment was the administration of drug at least 6 hours before stent implantation. GPIIb-IIIa antagonists were administered in only 13.9% of patients. Mace were observed in 2% of the patients. Factors correlated with Mace by univariate and multivariate analyses were: age > 73 years (RR: 2.37; 95% CI: 1.05-5.36, P < 0.037), previous myocardial infarction (RR: 2.56; 95% CI: 1.08-6.11, P < 0.034), pretreatment by T or C (RR: 0.389; 95% CI: 0.16-0.95, P < 0.038). In patients who did not receive GPIIb-IIIa antagonists, age > 73, and pretreatment by T or C were the only independent predictors of Mace.

[What do registries bring us? The example of acute coronary syndromes]

Prospective, randomised trials are the key to evidence-based medicine. They have brought considerable progress to the field of cardiology. They have, however, methodological constraints that result in the inclusion of only a small proportion of patients presenting with a given disease. In contrast, registries include all patients, without any selection, and therefore reflect everyday practice in the "real world". They are the key to epidemiological data, but they can also be used to tackle questions or issues that are unresolved by randomised trials. Both approaches are complementary and should be used to define the optimal management of patients. Lessons derived from registry data in acute coronary syndromes in the recent past in France are presented.

[Beating heart in "aortic no-touch off-pump" techniques: a simple answer to complex surgical situations]

Three cases reports illustrate the concept of beating heart cardiac surgery and its advantages regarding the prevention of arterial emboli.

[Efficacy of early reperfusion therapy at the acute stage of myocardial infarction in elderly patients: the USIK database]

The role of early reperfusion therapy at the acute stage of myocardial infarctus in elderly patients is debated. The aim of this study was to analyze the prognostic role of reperfusion with i.v. thrombolysis or primary PTCA in the nationwide USIK database, which prospectively included all pts admitted to a CCU for an AMI < 48 hours in France in November 1998. For the purpose of the present study, only patients admitted within 24 hours of AMI and with one-year follow-up available were included. Of the 1838 patients included, 785 were > 70 years-old, of whom 225 (29%) had early reperfusion therapy with thrombolysis (N = 173) or primary PTCA (N = 52). Patients treated with early reperfusion had a baseline profile that differed substantially from that of patients treated conventionally: women (31% vs 50%, p < 0.001), admission within six hours of symptom onset (84% vs 55%, p < 0.001), history of systemic hypertension (48% vs 60%, p < 0.002), stroke (5% vs 11%, p < 0.01), peripheral arterial disease (8% vs 18%, p < 0.001); congestive heart failure (5% vs 20%, p < 0.001) or previous MI (12% vs 25%, p < 0.001), more anterior location of current MI (40% vs 28%, p < 0.002). Overall one-year Kaplan-Meier survival was 78% for patients with versus 64% for those without reperfusion therapy (p < 0.01). In patients with Q wave myocardial infarction, Cox multivariate analysis showed that reperfusion therapy was an independent predictor of survival (RR 0.66; 95% Confidence Interval: 0.45-0.96), along with age, anterior location and history of congestive heart failure. Therefore, data from this large "real life" registry indicate that reperfusion therapy with either thrombolysis or primary PTCA is associated with improved one-year survival in patients over 70 years of age.