Highlights
- •Among 8252 patients 39 % were candidates for abbreviated DAPT and 37.8 % for prolonged DAPT.
- •The candidate to abbreviated DAPT had higher risk of all-cause (HR: 1.96) and cardiovascular (HR: 2.10) mortality.
- •Patients' candidate to short or prolonged DAPT had higher risk of MACE.
- •Candidates to abbreviated DAPT had higher risk of MB (sHR: 2.84).
Abstract
Background
Current evidence supports the efficacy of prolonged dual antiplatelet treatment (DAPT)
for patients at high-ischemic risk and low bleeding risk as well as the efficacy and
safety of short DAPT in high-bleeding risk (HBR) patients.
Methods
We evaluated patterns of DAPT candidates in all patients discharged in 2 hospitals
after an acute coronary syndrome (ACS). Patients categorized in 3 groups: 1) short-DAPT
candidates if they met 1 major o 2 minor criteria for HBR, by the 2019 ARC-HBR criteria;
2) prolonged-DAPT candidates if were not HBR and had recurrent ACS, complex percutaneous
coronary interventions or diabetes; 3) standard 12 months DAPT if were not include
in the previous 2 groups. Major bleeding (MB) was registered according to 3 or 5 of
the BARC consortium definitions.
Results
We included 8252 patients and 3215 (39 %) were candidates for abbreviated DAPT, 3119
(37.8 %) for prolonged DAPT, and 1918 (23.2 %) for 12 m DAPT. Relevant differences
were observed between the 3 categories beyond the bleeding risk. Median follow-up
was 57 months. Multivariate analysis identified higher risk of all-cause mortality
(HR: 1.96 95 % CI 1.45–2.67; p < 0.001), cardiovascular mortality (HR: 2.10 95 % CI
1.39–3.19; p < 0.011), MACE (HR: 1.69 95 % 1.50–2.02; p < 0.001) and MB (sHR: 3.41
95 % CI 1.45–8.02; p = 0.005) in candidates to short DAPT. Candidates to prolonged
DAPT had higher risk of MACE (HR: 1.17 95 % CI 1.02–1.35; p = 0.027).
Conclusions
Almost two thirds of patients discharged after an ACS would be candidates for short
or prolonged DAPT and these patients are at higher risk of MACE and mortality.
Graphical abstract
Graphical Abstract
Keywords
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References
- 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).Eur. Heart J. 2017; 39: 119-177
- 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC).Eur. Heart J. 2020; 42: 1289-1367
- 2018 ESC/EACTS guidelines on myocardial revascularization.Eur. Heart J. 2019; 40: 87-165
- Ticagrelor with or without aspirin in high-risk patients after PCI.N. Engl. J. Med. 2019; 381: 2032-2042
- Effect of ticagrelor monotherapy vs ticagrelor with aspirin on major bleeding and cardiovascular events in patients with acute coronary syndrome: the TICO randomized clinical trial.JAMA. 2020; 323: 2407-2416
- Dual antiplatelet therapy after PCI in patients at high bleeding risk.N. Engl. J. Med. 2021; 385: 1643-1655
- Risk-benefit of 1-year DAPT after DES implantation in patients stratified by bleeding and ischemic risk.J. Am. Coll. Cardiol. 2021; 78: 1968-1986
- Vascular smooth muscle cells in atherosclerosis: time for a re-assessment.Cardiovasc. Res. 2021; 117: 2326-2339
- Long-term use of ticagrelor in patients with prior myocardial infarction.N. Engl. J. Med. 2015; 372: 1791-1800
- Duration of antiplatelet therapy after complex PCI in the TWILIGHT-COMPLEX trial: the goldilocks dilemma.Cardiovasc. Res. 2020; 116: e93-e95
- Additive value of the CRUSADE score to the GRACE score for mortality risk prediction in patients with acute coronary syndromes.Int. J. Cardiol. 2017; 245: 1-5
- Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials.Lancet. 2017; 389: 1025-1034
- Efficacy and safety of dual antiplatelet therapy after complex PCI.J. Am. Coll. Cardiol. 2016; 68: 1851-1864
- Long-term bleeding risk vs. mortality risk in acute coronary syndrome patients according to the 2019 ARC-HBR definition.Thromb Res. 2020; 196: 516-518
- Temporal trends between association of evidence-based treatment and outcomes in patients with non-ST-elevation myocardial infarction.Int. J. Cardiol. 2018; 260: 1-6
- Incidence and predictors of stroke in patients discharged with the diagnosis of acute coronary syndrome.Int. J. Cardiol. 2019; 276: 20-25
- Defining high bleeding risk in patients undergoing percutaneous coronary intervention: a consensus document from the academic research consortium for high bleeding risk.Eur. Heart J. 2019; 40: 2632-2653
- Predictors of hospital mortality in the global registry of acute coronary events.Arch. Intern. Med. 2003; 163: 2345-2353
- A new equation to estimate glomerular filtration rate.Ann. Intern. Med. 2009; 150: 604-612
- Standardized bleeding definitions for cardiovascular clinical trials.Circulation. 2011; 123: 2736-2747
- Insuficiencia cardiaca de novo tras un síndrome coronario Agudo en pacientes sin insuficiencia cardiaca ni disfunción ventricular izquierda.Rev. Esp. Cardiol. 2021; 74: 494-501
- A proportional hazards model for the subdistribution of a competing risk.J. Am. Stat. Assoc. 1999; 94: 496-509
- Prior adherence to recommended lipid control targets in patients admitted for acute coronary syndrome.Rev. Esp. Cardiol. (Engl. Ed). 2020; 73: 376-382
- Predicting bleeding risk by simplified PRECISE-DAPT score.Thromb. Res. 2020; 195: 72-73
- Neutrophil extracellular traps (NETs) in patients with STEMI. Association with percutaneous coronary intervention and antithrombotic treatments.Thromb. Res. 2022; 213: 78-83
- Gender-related differences in post-discharge bleeding among patients with acute coronary syndrome on dual antiplatelet therapy: a BleeMACS sub-study.Thromb. Res. 2018; 168: 156-163
- Evaluation of the use of dual antiplatelet therapy beyond the first year after acute coronary syndrome.J. Clin. Med. 2022; 11
- Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without st-segment elevation.New England Journal of Medicine. 2001; 345: 494-502
- Early and sustained dual oral antiplatelet therapy following percutaneous coronary InterventionA randomized controlled trial.JAMA. 2002; 288: 2411-2420
- Prasugrel versus clopidogrel in patients with acute coronary syndromes.N. Engl. J. Med. 2007; 357: 2001-2015
- Ticagrelor versus clopidogrel in patients with acute coronary syndromes.N. Engl. J. Med. 2009; 361: 1045-1057
- Ticagrelor with or without aspirin after PCI: the TWILIGHT platelet substudy.J. Am. Coll. Cardiol. 2020; 75: 578-586
- Badimon perfusion chamber: an ex vivo model of thrombosis.in: Ishikawa K. Experimental Models of Cardiovascular Diseases: Methods and Protocols. Springer New York, New York, NY2018: 161-171
- Comparative effects of guided vs. potent P2Y12 inhibitor therapy in acute coronary syndrome: a network meta-analysis of 61 898 patients from 15 randomized trials.Eur. Heart J. 2022; 43: 959-967
- Efficacy and safety with ticagrelor in patients with prior myocardial infarction in the approved European label: insights from PEGASUS-TIMI 54.Eur. Heart J. Cardiovasc. Pharmacother. 2019; 5: 200-206
- Temporal trends in bleeding events in acute myocardial infarction: insights from the SWEDEHEART registry.Eur. Heart J. 2019; 41: 833-843
- Safety and efficacy of different P2Y12 inhibitors in patients with acute coronary syndromes stratified by the PRAISE risk score: a multicentre study.Eur. Heart J. Qual. Care Clin. Outcomes. 2022; 8: 881-891
Article info
Publication history
Published online: February 15, 2023
Accepted:
February 13,
2023
Received in revised form:
February 3,
2023
Received:
December 6,
2022
Identification
Copyright
© 2023 Elsevier Ltd. All rights reserved.
