Efficacy and Safety of Dual Antiplatelet Therapy After Complex PCI

Giustino, Gennaro; Chieffo, Alaide; Palmerini, Tullio; Valgimigli, Marco; Feres, Fausto; Abizaid, Alexandre; Costa, Ricardo; Hong, Myeong Ki; Kim, Byeong Keuk; Jang, Yangsoo; Kim, Hyo Soo; Park, Kyung Woo; Gilard, Martine; Morice, Marie Claude; Sawaya, Fadi J.; Sardella, Gennaro; Généreux, Philippe; Redfors, Björn; Leon, Martin B.; Bhatt, Deepak L.; Stone, Gregg W.; Colombo, Antonio

doi:10.1016/j.jacc.2016.07.760

Cited by 365 publications

(328 citation statements)

References 22 publications

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“…Long-term DAPT was associated with increased risk for major bleeding, which was similar between groups. 45 Results were consistent by per-treatment landmark analysis and further establish procedural complexity as an important parameter to take into account in tailoring upfront duration of DAPT. 38 A large individual patient data pairwise and network meta-analysis comparing short-term (< _6-months) vs. long-term (1-year) DAPT as well as 3-month vs. 6-month vs. 1-year DAPT included 11 473 patients.…”

Section: Dual Antiplatelet Therapy Durationsupporting

confidence: 62%

“…44 Another study pooled patient-level data from six randomized controlled trials and investigated the efficacy and safety of long-term (> _12 months) vs. short-term (3 or 6 months) DAPT with aspirin and clopidogrel after PCI. 45 Of 9577 patients included in the pooled data- 1.35; P-value for interaction = 0.01). The magnitude of the benefit with long-term DAPT was progressively greater per increase in procedural complexity.…”

Section: Dual Antiplatelet Therapy Durationmentioning

confidence: 99%

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The year in cardiology 2017: coronary interventions

Kristensen

Mæng

Capodanno

et al. 2018

European Heart Journal

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PreambleThe first balloon coronary angioplasty was performed in Zurich by Andreas Grüntzig in 1977. The patient, a 38-year-old man with severe angina and a tight stenosis on the left anterior descending artery, is still alive, is doing well, and he celebrated the 40-year anniversary of his percutaneous coronary interventions (PCI) in 2017 ( Figure 1). During the last decades, PCI techniques have undergone major improvements with the first real game changer being the introduction of bare metal stents, which made PCI safer and improved longer-term outcomes. Later on, drug-eluting stents (DESs) were introduced, which resulted in a major reduction in restenosis and also-with the newer generation DES-a low rate of stent thrombosis. Further, the introduction of intracoronary pressure measurements for assessment of severity of coronary stenoses [fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR)] and intracoronary imaging [intravascular ultrasound (IVUS) and optical coherence tomography (OCT)] for lesion assessment has refined lesion and procedure assessment. Improved outcomes were also fostered by development of better and safer adjunctive antithrombotic drugs and secondary prevention, optimizing drug-device synergy. Still, 40 years later the research in the coronary interventional field is very intense, and we aim here to summarize major developments in PCI published in 2017. Myocardial revascularization Percutaneous coronary intervention techniqueThe SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) II study investigated the impact of a contemporary PCI strategy on clinical outcomes of 454 patients with three-vessel disease. 1Characteristics of the SYNTAX II strategy that captures all components of today's 'best of PCI practice' are summarized in Figure 2. Following this approach systematically, the authors demonstrated major adverse cardiac and cerebrovascular events (MACCE) at 1 year to be much improved with respect to a matched historical PCI cohort from the SYNTAX I trial (10.6% vs. 17.4%; P = 0.006). The better result of the contemporary PCI strategy compared with the procedural technique followed at the time of the SYNTAX I trial was driven by a lower risk of myocardial infarction (MI) and revascularization, with a parallel reduction in stent thrombosis. Overall, the SYNTAX II study suggests that the combination of best practice components in PCI technique portends improved patient outcomes beyond what can be achieved by introducing one single new element. Because these results outperform PCI results obtained in the earlier SYNTAX I trial, the hypothesis was generated that a new randomized study of modern best PCI practice in patients with three-vessel disease might show non-inferiority vs. coronary artery bypass grafting (CABG). 1Glimpsing to the future, the feasibility and technical success of robotically-assisted PCI for complex coronary lesions were investigated in 334 procedures from 315 patients included in the Complex Robotically Assisted Percutaneous Coronary Intervention (...

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Section: Dual Antiplatelet Therapy Durationsupporting

confidence: 62%

Section: Dual Antiplatelet Therapy Durationmentioning

confidence: 99%

The year in cardiology 2017: coronary interventions

Kristensen

Mæng

Capodanno

et al. 2018

European Heart Journal

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“…A prolonged DAPT regimen prevents recurrent or new MI related or not to stent thrombosis. Furthermore, procedural complexity has emerged as an important driver of DAPT duration, with prolonged DAPT being beneficial in more‐complex procedures 20. Accordingly, it is plausible that different operators with different technical skills, expertise, and case volume, as well as different procedural tactics (predilatation and postdilatation, duration and pressure of dilatation, stent implantation sizing and technique, use of intravascular imaging modalities, etc) may be associated with different clinical outcomes.…”

Section: Discussionmentioning

confidence: 99%

Stent and Dual Antiplatelet Therapy Duration Comparisons in the Setting of a Multicenter Randomized Controlled Trial: Can the Operator Experience Affect the Study Results?

Gargiulo

Heg

Ferrari

et al. 2017

JAHA

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BackgroundOperator experience influences outcomes after percutaneous coronary intervention, but this association in the controlled setting of a randomized, clinical trial is unclear.Methods and ResultsWe investigated operator‐related outcomes (30‐day and 2‐year efficacy and safety end points) among patients undergoing percutaneous coronary intervention and randomized to different dual antiplatelet therapy durations and stent types. A total of 2003 patients were analyzed, and 7 operator groups were compared. The majority of preprocedural and postprocedural characteristics were imbalanced. The primary end point of the study, the composite of death, myocardial infarction, or cerebrovascular accidents, did not differ among operators at 30 days or 2 years. There were no significant differences also for all other individual and composite end points analyzed at 30 days and 2 years, except for 2‐year stent thrombosis (P=0.048) and bleeding events (P=0.022 for Bleeding Academic Research Consortium type 2, 3, or 5). Adjusted comparisons for the main end points showed slight differences among operators at 30 days, but not at 2 years. There was no interaction of operator with dual antiplatelet therapy duration (P=0.112) or stent type (P=0.300). Results remained entirely consistent when operators were stratified by their experience.ConclusionsThere was a weak signal of heterogeneity across study operators for the 30‐day, but not the 2‐year, main study outcomes. No clear effect of operator or operator experience was observed for the comparative efficacy and safety profile of the randomized stent types or dual antiplatelet therapy duration regimens.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00611286.

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“…However, our rare patient was in low-bleeding risk [1]. In addition, he had a history remarkable for increased procedural PCI complexity (three stents implanted, three lesions treated, total stent length >60 mm); in this subset of patients, novel data provides evidence that longitudinal DAPT may bear a significant clinical benefit [3]. In line with the latter, our case highlights the critical role of complex PCI for very late stent thrombosis and stresses the importance of long-term DAPT in low-bleeding risk patients even in the absence of other predisposing ischemic risk factors.…”

Section: Case Reportmentioning

confidence: 99%

Discontinuation of prolonged dual antiplatelet therapy for a dental extraction; A nearly-fatal decision

Papanikolaou¹,

Platogiannis²,

Gkekas³

et al. 2017

Interventional-Cardiology.

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Stent thrombosis remains one of the most feared complications in patients with multiple stents implanted. In this clinical setting, optimal upfront dual antiplatelet therapy (DAPT) duration still remains controversial. Herein, we wish to report a case of life-threatening very-late stent thrombosis after DAPT temporary discontinuation, highlighting the prolonged increased thrombotic risk of complex angioplasty, even in otherwise low-ischemic risk patients according to recent recommendations. Our data are in line with novel information and might be useful in the pre-operative management of patients with complex percutaneous coronary intervention (PCI). Keywords: Dual antiplatelet therapy  Percutaneous coronary intervention  Stable ischemic heart disease  Stent thrombosis  Cardiogenic shock  Glycoprotein IIb/IIIa inhibitors Case ReportA 66-year-old hypertensive man presented with an acute anterior ST-elevation myocardial infarction (STEMI) and ensuing cardiogenic shock, five years after implantation of three drug-eluting (DES) stents in proximal left anterior descending (LAD), proximal first diagonal branch and circumflex artery (LCX) (Figures 1A-1D) for stable ischemic heart disease. The patient was asymptomatic since then; however, three days before his admission, he was advised to temporarily discontinue aspirin-clopidogrel DAPT for a minimal dental procedure (tooth extraction), and receive low molecular weight heparin (LMWH) as a five-day bridging therapy regimen.The patient was transferred immediately to the catheterization laboratory; while coronary artery angiography (CAA) was in progress, however, he demonstrated devastating cardiogenic shock (noradrenaline dose ≤42 mcg/min) and electrical storm (numerous episodes of ventricular tachycardia/ fibrillation), thus he was intubated and received several cycles of cardiopulmonary resuscitation and electrical cardioversion/ defibrillation. CAA disclosed total left main artery (LMA) occlusion with a Thrombolysis in Myocardial Infarction (TIMI) flow grade of 0, implying generalized acute stent thrombosis ( Figure 1A, Online Video 1). While the patient was in premortal shockOnline Video 1: Pre-interventional LAO coronary angiographic view with 30° cranial angulation, revealing a total LMA occlusion with TIMI flow grade of 0, as well as the three previously implanted drug-eluting stents in proximity to the lesion. LAO=left anterior oblique; LMA=left main artery; TIMI=Thrombolysis in Myocardial Infarction.

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Efficacy and Safety of Dual Antiplatelet Therapy After Complex PCI

Abstract: Alongside other established clinical risk factors, procedural complexity is an important parameter to take into account in tailoring upfront duration of DAPT.

Cited by 365 publications

References 22 publications

The year in cardiology 2017: coronary interventions

The year in cardiology 2017: coronary interventions

Stent and Dual Antiplatelet Therapy Duration Comparisons in the Setting of a Multicenter Randomized Controlled Trial: Can the Operator Experience Affect the Study Results?

Discontinuation of prolonged dual antiplatelet therapy for a dental extraction; A nearly-fatal decision

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