Abstract
(1) Shorter-duration dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy has been shown to significantly reduce bleeding events while preserving anti-ischemic effects in patients undergoing conventional percutaneous coronary interventions (PCI). Whether this strategy is also safe and effective in complex PCI remains elusive; (2) A systematic search of randomized controlled trials comparing a short course of ticagrelor-based DAPT versus standard DAPT in patients undergoing complex PCI was performed; (3) Of 10,689 studies screened, 3 were identified for a total of 4176 participants on ticagrelor monotherapy after a short course of ticagrelor-based DAPT, and 4209 on standard DAPT. The pooled analysis revealed no difference in the outcomes of major bleeding, myocardial infarction, definite or probable stent thrombosis and ischemic stroke. A significant reduction in the risk of cardiovascular death (incidence rate ratio (IRR) 0.52; 95% CI 0.28–0.96; p = 0.04), all-cause death (IRR 0.65; 95% CI 0.49–0.86; p = 0.003), and any bleeding events (IRR 0.62; 95% CI 0.47–0.81; p < 0.001) was seen in the shorter DAPT group; (4) Among patients undergoing complex PCI, ticagrelor monotherapy after a short course of ticagrelor-based DAPT significantly reduced bleeding risk without increasing ischemic risk. More data are needed to definitively explain mortality benefits.
Highlights
Current guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 6 months in patients with stable coronary artery disease (CAD) after percutaneous coronary intervention (PCI)
The standard regimen was ticagrelor plus aspirin for 12 months in one study [13] and for 15 months in one study [12], while a regimen based on 12-month DAPT followed by 12-month aspirin monotherapy was adopted in one study [11]
The impact of minor bleeding on survival is associated with several factors: location, severity, timing, DAPT discontinuation to manage bleeding, anemia potentially leading to ischemia and greater propensity to arrhythmias due to mismatch between oxygen supply and demand, and discontinuation of other therapies in order to treat hypotension after bleeding, such as beta-blockers and renin–angiotensin–aldosterone system inhibitors, often discontinued and no longer reintroduced [14]
Summary
Current guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 6 months in patients with stable coronary artery disease (CAD) after percutaneous coronary intervention (PCI). Patients with more advanced CAD and requiring complex PCI for revascularization are at an increased risk for adverse ischemic events [2]. Multiple risk scores are available to assess patient ischemic and/or bleeding risk (PARIS, ACUITY, CRUSADE, ARC-HBR, Blee-MACS risk scores) [3], but only two are currently recommended by the European Society of Cardiology (ESC) to guide and inform decision making on DAPT duration, with a IIb level of recommendation: the PRECISE-DAPT score and the DAPT score. Careful evaluation of clinical and procedural characteristics at an individual patient level is essential in determining the optimal antiplatelet strategy, in patients at high risk for adverse ischemic events
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