Prolonged dual antiplatelet therapy after drug-eluting stent implantation improves long-term prognosis for acute coronary syndrome: five-year results from a large cohort study

BACKGROUND

To investigate the most appropriate dual antiplatelet therapy (DAPT) duration for patients with acute coronary syndrome (ACS) after drug-eluting stent (DES) implantation in the largest cardiovascular center of China.

METHODS

We enrolled 5,187 consecutive patients with ACS who received DES from January to December 2013. Patients were divided into four groups based on DAPT duration: standard DAPT group (11-13 months, n=1,568) and prolonged DAPT groups (13-18 months [n=308], 18-24 months [n=2,125], and >24 months [n=1,186]). Baseline characteristics and 5-year clinical outcomes were recorded.

RESULTS

Baseline characteristics were similar across the four groups. Among the four groups, those with prolonged DAPT (18-24 months) had the lowest incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) (14.1% vs. 11.7% vs. 9.6% vs. 24.2%, P<0.001), all-cause death (4.8% vs. 3.9% vs. 2.1% vs. 2.6%, P<0.001), cardiac death (3.1% vs. 2.6% vs. 1.4% vs. 1.9%, P=0.004), and myocardial infarction (MI) (3.8% vs. 4.2% vs. 2.5% vs. 5.8%, P<0.001). The incidence of bleeding was not different among the four groups (9.9% vs. 9.4% vs. 11.0% vs. 9.4%, P=0.449). Cox multivariable analysis showed that prolonged DAPT (18-24 months) was an independent protective factor for MACCEs (hazard ratio [HR] 0.802, 95% confidence interval [CI] 0.729-0.882, P<0.001), all-cause death (HR 0.660, 95% CI 0.547-0.795, P<0.001), cardiac death (HR 0.663, 95% CI 0.526-0.835, P<0.001), MI (HR 0.796, 95% CI 0.662-0.957, P=0.015), and target vessel revascularization (HR 0.867, 95% CI 0.755-0.996, P=0.044). Subgroup analysis for high bleeding risk showed that prolonged DAPT remained an independent protective factor for all-cause death and MACCEs.

CONCLUSION

For patients with ACS after DES, appropriately prolonging the DAPT duration may be associated with a reduced risk of adverse ischemic events without increasing the bleeding risk.

A comparison of drug-eluting stent and coronary artery bypass grafting in mildly to moderately ischemic heart failure

Aims

The best revascularization strategy for patients with ischaemic heart failure (IHF) remains unclear. Current evidence and guidelines mainly focus on patients with severe ischaemic heart failure (ejection fraction [EF] < 35%). There are limited data comparing clinical outcomes of coronary artery bypass grafting (CABG) with implantation of drug‐eluting stents (DESs) in patients with mild to moderate ischaemic heart failure (EF 35–50%). It is therefore unknown whether percutaneous coronary intervention (PCI) with DES implantation can provide comparable outcomes to CABG in these patients.

Methods and results

From January 2016 to December 2017, we enrolled patients with mildly to moderately reduced EF (35–50%) who had undergone PCI with DESs or CABG. Patients with a history of CABG, presented with acute ST‐elevation myocardial infarction (MI) or acute heart failure, and patients who had undergone CABG concomitant valvular or aortic surgery were excluded. Propensity score‐matching analysis was performed between the two groups. Kaplan–Meier analysis and multivariate Cox proportional hazard regression were applied to assess all‐cause mortality and individual end points. A total of 2050 patients (1330 PCIs and 720 CABGs) were included, and median follow‐up was 45 months (interquartile range 40 to 54). There were significant differences in all‐cause death between the two groups: 77 patients in the PCI group and 27 in the CABG group (DES vs. CABG: 5.8% vs. 3.8%, P = 0.045). After propensity score matching for the entire population, 601 matched pairs were obtained. The long‐term cumulative rate of all‐cause death was significantly different between the two groups (DES vs. CABG: 5.8% vs. 2.7%, P = 0.006). No differences were found in the rates of cardiac death (DES vs. CABG: 4.8% vs. 3.0%, P = 0.096), recurrent MI (DES vs. CABG: 4.0% vs. 2.8%, P = 0.234), and stroke (DES vs. CABG: 6.8% vs. 5.2%, P = 0.163). The rate of repeat coronary revascularization was significantly higher in the PCI group than in the CABG group (12.1% vs. 6.0%, P = 0.000).

Conclusions

Considering the higher long‐term survival rate and lower repeat‐revascularization rate, CABG may be superior to DES implantation in patients with mildly to moderately reduced EF (35–50%) and significant CAD.

Utility of a pharmacogenetic-driven algorithm in guiding dual antiplatelet therapy for patients undergoing coronary drug-eluting stent implantation in China

PURPOSES

The POPular Risk Score (PRiS), a pharmacogenetic-driven algorithm consisting of CYP2C19 genotype, platelet reactivity, and clinical risk factors, is developed to evaluate ischemic risk and guide dual antiplatelet therapy (DAPT). This study aimed to evaluate the efficacy and safety of DAPT in accordance with the PRiS in patients undergoing drug-eluting stent (DES) implantation.

METHODS

A total of 1757 patients recruited in this cohort study were divided into four groups according to the PRiS and type of P2Y12 receptor inhibitor treatment at discharge. The primary endpoint was major adverse cardiovascular events (MACE, a composite of cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis, and target vessel revascularization) during 1-year follow-up. The safety endpoints were defined by Bleeding Academic Research Consortium (BARC) criteria as major bleeding (BARC 3a, 3b, 3c, and 5) and clinically relevant bleeding (BARC 2, 3a, 3b, 3c, and 5).

RESULTS

Among 1046 patients with PRiS < 2 and 711 patients with PRiS ≥ 2, 34.2% and 38.3% of them were treated with ticagrelor, respectively. The PRiS ≥ 2 was an independent predictor for the 1-year incidence of MACE (HR(95%CI): 2.09 (1.37-3.20), p = 0.001). Multivariable Cox regression indicated that in the PRiS ≥ 2 group, ticagrelor was superior to clopidogrel in reducing the risk of MACE (HR(95%CI): 0.53 (0.29-0.98), p = 0.042), without increasing the bleeding risk. On the other hand, in the PRiS < 2 group, clopidogrel treatment was related to a remarkably lower rate of BARC class ≥ 2 bleeding (HR(95%CI): 0.39 (0.20-0.72), p = 0.003), but comparable incidences of MACE and BARC class ≥ 3 bleeding during 1-year follow-up. Similar associations between P2Y12 receptor inhibitors and 1-year endpoints in the PRiS < 2 and PRiS ≥ 2 group could also be identified in propensity score-weighted analysis and propensity score-matched analysis.

CONCLUSION

Tailored DAPT based on the PRiS could assist in improving the prognosis of patients undergoing DES implantation. Further randomized controlled trials are required to provide more evidence for PRiS-guided DAPT.

Assessment of the LDL-C/HDL-C ratio as a predictor of one year clinical outcomes in patients with acute coronary syndromes after percutaneous coronary intervention and drug-eluting stent implantation

Background

Despite significant advances in the management of acute coronary syndromes (ACS), there are still plenty of patients undergoing percutaneous coronary intervention (PCI) and stent implantation suffered poor prognosis and high treatment expenditure. Evidence increasingly suggests that the ratio of low-density lipoprotein cholesterol/high-density lipoprotein cholesterol (LDL-C/HDL-C) ratio might be a novel marker for the risk of atherosclerotic cardiovascular disease, but the impact of LDL-C/HDL-C ratio on 1-year prognosis of drug-eluting stent (DES) implantation patients after PCI is still not reported. Our aim of the study was to investigate the impact of LDL-C/HDL-C ratio on 1-year prognosis of DES implantation patients after PCI.

Methods

Between May 2014 and July 2016, 1937 patients who were underwent primary PCI and DES implantation and achieving LDL-C with statins were enrolled and divided into two groups based on the ratio of LDL-C/HDL-C.

Results

The entire occurrence of adverse cardiovascular events according to the ratio of LDL-C/HDL-C showed that there were no significant differences in 1-year cardiovascular death (hazard ratio [HR]: 1.97, 95% confidence interval [CI]: 0.49 to 7.84, P = 0.329), myocardial infarction (MI) (HR: 1.66, 95% CI: 0.84 to 3.28, P = 0.172) and bleeding events (HR: 1.08, 95% CI: 0.83 to 1.41, P = 0.598) The cumulative incidence of target lesion revascularization (TLR) (HR: 1.43, 95% CI: 1.10 to 1.86, P = 0.007), stent thrombosis (ST) (HR: 2.04, 95% CI: 1.06 to 3.93, P = 0.037) and major adverse cardiac events (MACE) (HR: 1.54, 95% CI: 1.24 to 1.91, P <  0.001) were significantly higher in high group than in low group. Multivariate Cox regression analysis revealed that age (HR: 1.556, 95%, CI: 1.198 to 2.021, P <  0.001), together with diabetes mellitus (HR: 1.490, 95% CI: 1.142 to 1.945, P = 0.003), and ratio of LDL-C/HDL-C (HR: 1.638, 95% CI: 1.260 to 2.218, P <  0.001) were independent predictors of 1-year MACE. The Kaplan-Meier cumulative MACE-free survival curves with a log-rank test showed that the presence of high ratio of LDL-C/HDL-C was associated with higher incidences of MACE after PCI with DES implantation.

Conclusions

The high LDL-C/HDL-C ratio was associated with cardiovascular events in patients with ACS after PCI and DES implantation.

A new scoring system (DAIGA) for predicting bleeding complications in atrial fibrillation patients after drug-eluting stent implantation with triple antithrombotic therapy

BACKGROUND

No scoring system for evaluating the bleeding risk of atrial fibrillation (AF) patients after drug-eluting stent (DES) implantation with triple antithrombotic therapy (TAT) is available. We aimed to develop a new scoring system for predicting bleeding complications in AF patients after DES implantation with TAT.

METHODS AND RESULTS

Between April 2007 and April 2014, 227 AF patients undergoing DES implantation with TAT were enrolled. Bleeding incidence defined as Bleeding Academic Research Consortium criteria≥2 was investigated and predictors of bleeding complications were evaluated using multivariate analysis. Bleeding complications occurred in 58 patients (25.6%) during follow-up. Multivariate analysis revealed dual antiplatelet therapy (DAPT) continuation (OR 3.33, P=0.01), age>75 (OR 2.14, P=0.037), international normalized ratio>2.2 (OR 5.82, P<0.001), gastrointestinal ulcer history (OR 3.06, P=0.037), and anemia (OR 2.15, P=0.042) as predictors of major bleeding complications. A score was created using the weighted points proportional to the beta regression coefficient of each variable. The DAIGA score showed better predictive ability for bleeding complications than the HAS-BLED score (AUC: 0.79 vs. 0.62, P=0.0003). Bleeding incidence was well stratified: 17.8% in low-risk (scores 0-1), 55.5% in moderate-risk (2-3), and 83.0% in high-risk (4-7) patients (P<0.001).

CONCLUSIONS

This scoring system is useful for predicting bleeding complications and risk stratification of AF patients after DES implantation with TAT.