Optimal Strategy for Antiplatelet Therapy After Coronary Drug-eluting Stent Implantation in High-risk
Haoyu Wang1, Bo Xu2, Yuejin Yang2, Dong Yin2, Kefei Dou2
Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China1, Fuwai Hospital, China2
Patients with diabetes mellitus (DM) are known to be at high-risk for both ischemic and bleeding complications post-percutaneous coronary intervention (PCI). The ischemic beneﬁt vs. bleeding risk associated with extended dual antiplatelet therapy (DAPT) in high-risk “TWILIGHT-like” patients with diabetes mellitus after PCI has not been established.
All consecutive high-risk patients fulﬁlling the “TWILIGHT-like” criteria undergoing PCI from January 2013 through December 2013 were identiﬁed from the prospective Fuwai PCI Registry. High-risk “TWILIGHT-like” patients were deﬁned by at least one clinical and one angiographic feature based on the TWILIGHT trial selection criteria. The present analysis evaluated 3,425 diabetic patients with concomitant high-risk angiographic features who were event-free at 1 year after PCI. Median follow-up was 2.4 years. The primary effectiveness endpoint was a composite of death, myocardial infarction, or stroke (termed major adverse cardiac and cerebrovascular events), and primary safety endpoint was clinically relevant bleeding according to the Bleeding Academic Research Consortium types 2, 3, or 5.
On inverse probability of treatment weighting (IPTW) analysis, prolonged-term (>1-year) DAPT with aspirin and clopidogrel decreased the risk of primary effectiveness endpoint compared with shorter (≤1-year) DAPT (1.8% vs. 4.3%; hazard ratio [HR]IPTW: 0.381; 95% confidence interval [CI]: 0.252-0.576; P<0.001) and reduced cardiovascular death (0.1% vs. 1.8%; HRIPTW: 0.056 [0.016-0.193]). Prolonged DAPT was also associated with a reduced risk of definite/probable stent thrombosis (0.2% vs. 0.7%; HRIPTW: 0.258 [0.083-0.802]), and non-significantly lower rate of myocardial infarction (0.5% vs. 0.8%; HRIPTW: 0.676 [0.275-1.661]). There was no significant difference between groups in clinically relevant bleeding (1.1% vs. 1.1%; HRIPTW: 1.078 [0.519-2.241]; P=0.840). Similar results were observed in multivariable Cox proportional hazards regression model.
Among high-risk PCI patients with diabetes mellitus without an adverseevent through 1 year, extending DAPT>1-year significantly reduced the riskof major adverse cardiac and cerebrovascular events without an increase inclinically relevant bleeding, suggesting that such high-risk diabetic patientsmay be good candidates for long-term DAPT.