Author + information
- Leonardo De Luca, MD, PhD∗ ()
- Interventional Cardiology Unit, Division of Cardiology, San Giovanni Evangelista Hospital, Rome, Italy
- ↵∗Address for correspondence:
Dr. Leonardo De Luca, Interventional Cardiology Unit, Division of Cardiology, San Giovanni Evangelista Hospital, Via A. Parrozzani 3, Tivoli 00019 Rome, Italy.
Dual antiplatelet therapy (DAPT) is a pillar for the prevention of cardiovascular events following acute coronary syndromes and/or percutaneous coronary intervention (PCI) (1,2). Nevertheless, the optimal duration of DAPT is still debated. In the last decades several randomized trials have been conducted on this topic, demonstrating the beneficial effects of extending DAPT beyond the standard duration recommended by guidelines, in terms of stent- and non-stent-related recurrent ischemic events, counterbalanced by an increased risk of minor and major bleeding complications (1–3). Currently, to identify those patients who might benefit from a prolonged DAPT duration and those who might be exposed to an excessive risk of bleeding, clinicians are asked to balance the estimated hazard of ischemic and bleeding events based on a mindful evaluation of patient’s risk profile or using scores that include clinical and/or laboratory variables (1,2).
Recent evidences suggest that, beside well-established risk factors, clinicians also consider some PCI-related variables, such as the number of stents implanted, when a decision on DAPT duration is made (4). Indeed, patients who undergo complex PCI present by definition a higher stent-related thrombotic risk associated with the cumulative stent length, possible malapposition, incomplete lesion coverage, and delayed endothelization, even when new-generation drug-eluting stents are used (5). In this regard, emerging studies suggest that patients undergoing complex PCI procedures may benefit from a longer DAPT duration with a sequential clinical benefit as the number of complex angiographic features increases and with a magnitude similar to that of other well-established clinical risk factors (6,7).
In this issue of JACC: Cardiovascular Interventions, the clinical outcomes after left main bifurcation PCI using 1 or 2 new-generation drug-eluting stents and the impact of the duration of DAPT according to the treatment strategy have been investigated in a patient-level pooled analysis of 5 different multicenter observational studies conducted in Korea from 2008 to 2014 (8). The primary outcome of this analysis was the target lesion failure (TLF) and thrombotic adverse cardiovascular events (TACE; a composite of cardiac death, all-cause myocardial infarction, and definite or probable stent thrombosis) at 3 years (8). According to previous studies (9,10), rates of TLF and target lesion revascularization were higher in the 2-stent group, mainly driven by the more complex lesion profiles, whereas risks of TACE and its components were comparable between 2 groups. In the subgroup analysis, there was a significant interaction between DAPT interruption <1 year and the stenting strategy: the risk of TLF and TACE in the 2-stent group was significantly higher than the 1-stent group in those with premature DAPT discontinuation, whereas it was similar in the 2 groups in those receiving prolonged DAPT (8). The results were consistent also in the 1-year event-free landmark analysis performed as a sensitivity analysis. In addition, premature DAPT discontinuation was the only modifiable independent predictor of TLF in the 2-stent group, but it did not result as a predictor of TLF in the 1-stent group (8).
Although original in exploring the impact of DAPT duration in a relatively homogeneous population, the study presents a few limitations. First, because it was an observational analysis, an assessment based on the intention-to-treat for the DAPT duration was not allowed; moreover, details on the reasons for DAPT interruption or maintenance have not been fully collected. Consequently, a premature discontinuation can be simply a marker of the high event rate observed among patients treated with 2 stents on the left main. Indeed, patients who undergo complex PCI procedures may have a more extensive and severe coronary artery disease with an increased likelihood of incomplete myocardial revascularization, plaque progression or instability, and a higher prevalence of comorbidities. Second, all patients enrolled in the present analysis were treated with clopidogrel and data on drug resistance and platelet function were not systematically collected. Therefore, it is reasonable to postulate that with the use of novel P2Y12 inhibitors the benefits in terms of TACE could have been higher as the rate of major bleeding events.
In conclusion, the present study adds further evidence on the possible role of PCI complexity as ischemic risk factor for the optimization of DAPT and provides clues for future, larger, randomized clinical studies. Meanwhile, PCI variables seem to be another piece of the complex puzzle (Figure 1) that clinicians need to solve to maximize ischemic protection and minimize bleeding risks in each patient eligible for DAPT prolongation.
↵∗ Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology.
Dr. De Luca has received honoraria from Aspen, AstraZeneca, Bayer, Boehringer Ingelheim, Chiesi, Daiichi-Sankyo, Menarini, and Pfizer/Bristol-Myers Squibb.
- 2018 American College of Cardiology Foundation
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- for the ESC Scientific Document Group,
- ESC Committee for Practice Guidelines (CPG),
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- for the EYESHOT Post-MI Investigators
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