Long-Term DAPT Reduced MACE After Complex PCI

Dual antiplatelet therapy (DAPT) lasting at least 1 year was associated with significantly reduced risk of cardiac ischemic events following complex PCI.¹

In addition, the benefit was greater as the PCI procedure increased in complexity.

Results of the analysis were presented at the 2016 European Society of Cardiology Congress² this week in Rome, and simultaneously published in the Journal of the American College of Cardiology.

Gennaro Giustino, MD, of the Zena and Michael A. Wiener Cardiovascular Institute at Mount Sinai in New York, and colleagues  conducted a post hoc patient-level pooled analysis of randomized controlled trials investigating the efficacy and safety of long-term (≥1 year) vs short-term (3 or 6 months) DAPT in 9577 patients undergoing complex or non-complex PCI.

Of those, 1680 (17.5%) underwent complex PCI, which included at least 1 of the following: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, or chronic total occlusion.

Primary efficacy end point was MACE, defined as the composite of cardiac death, myocardial infarction (MI), or definite or probable stent thrombosis at median time of follow-up.

At a median follow-up time of 392 days, patients who underwent complex PCI had higher crude rates of MACE and chronic thrombotic event (CTE), MI, definite or probable ST, target vessel revascularization, and mortality. Complex PCI remained strongly associated with increased risk for MACE, CTEs, definite or probable stent thrombosis, and MI following multivariable Cox regression modeling.

Researchers found a significant MACE benefit for patients who underwent complex PCI (hazard ratio [HR]:0.56; 95% confidence interval [CI]: 0.35-0.89) compared with those who had non-complex PCI (adjusted HR: 1.01; 95% CI: 0.75-1.35; P for interaction=.01). They also noted that the MACE benefit of long-term DAPT increased as the number of high-risk procedural features increased.

Long-term DAPT was also associated with significantly reduced risk for CTEs in patients who underwent complex PCI (HR:0.57; 95% CI, 0.33-0.97) compared with non-complex PCI (adjusted HR: 0.87; 95% CI: 0.61-1.25; P for interaction=.04).

However, Dr Giustino and colleagues also observed an association between long-term DAPT and an increased risk for major bleeding that was uniform in magnitude and direction between patients with and without complex PCI.

Disclosures: Dr Palmerini has received various fees from Abbott Vascular and Eli Lilly, and Dr Valgimigli has received fees from Abbott Vascular, AstraZeneca, Alvimedica, Medtronic, Terumo, and The Medicines Company. Dr Feres has received speaker fees from Biosensors and Eli Lilly and has been a consultant for Medtronic and Scitech. Dr Bhatt has received research funding from Amarin, AstraZeneca, Bristol-Myeers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi, and The Medicines Company, among others.

References

1. Giustino G, Chieffo A, Palmerini T, et al. Efficacy and safety of dual antiplatelet therapy after complex PCI. J Am Coll Cardiol. 2016. doi:10.1016/j.jacc.2016.07.760.
2. Giustino G, Chieffo A, Palmerini T, et al. Abstract P4308. Safety and efficacy of prolonged dual antiplatelet therapy following complex percutaneous coronary artery revascularization with drug-eluting stents. Presented at European Society of Cardiology Congress. August 27-31, 2016; Rome, Italy.