Dual Antiplatelet Therapy Interruption Research Articles

One-month DAPT after biodegradable-polymer everolimus-eluting stent implantation in patients at high-bleeding risk: an individual patient data pooled analysis of the SENIOR and POEM trials.

Dual antiplatelet therapy (DAPT) can be shortened up to 1 month in high-bleeding risk (HBR) patients receiving a contemporary biodegradable-polymer sirolimus-eluting stent. We aimed to summarize the evidence on a similar DAPT regimen after biodegradable-polymer everolimus-eluting stent (EES) implantation in patients at HBR. We pooled the individual participant data from the available trials evaluating this strategy, namely, the SENIOR and the POEM trials. Inclusion criteria were ≥1 biodegradable-polymer EES implantation and ≤1-month duration of DAPT. The primary endpoint was the 1-year composite of cardiovascular death, myocardial infarction, or stroke. Major bleeding was defined as Bleeding Academic Research Consortium (BARC) type 3-5 bleeding. Landmark analyses were performed at 1 month, the time point for intended DAPT interruption. We included 766 participants (age 77.5 ± 8.2 years, women 31.9%), 323 from the SENIOR and 443 from the POEM trial. The primary endpoint occurred in 45 participants (6.0%; 95% confidence interval [CI], 4.3-7.7%) through 1 year of follow-up, with 21 (2.8%; 95% CI, 1.6-3.9%) events during the first month and 24 (3.4%; 95% CI, 2.0-4.7%) thereafter. The incidences of cardiovascular death, myocardial infarction, and stroke were 2.2% (95% CI, 0.36-2.50%), 3.1% (95% CI, 1.8-4.3%), and 1.2% (95% CI, 0.4-2.0%), respectively. BARC type 3-5 bleeding ocuurred in 1.1% (95% CI, 0.3-1.8%) at 1 month and 2.9% (95% CI, 1.6-4.1%) at 1 year. HBR patients receiving biodegradable-polymer EES had few ischemic and bleeding events when given 1 month of DAPT. One-month DAPT after biodegradable-polymer EES implantation seems safe in patients at HBR.

Coronary bypass surgery for multivessel disease after percutaneous coronary intervention in acute coronary syndromes: why, for whom, how early?

Multivessel coronary artery disease is present in ∼50% of patients with acute coronary syndrome and, compared with single-vessel disease, entails a higher risk of new ischaemic events and a worse prognosis. Randomized controlled trials have shown the superiority of 'complete revascularization' over culprit lesion-only treatment. Trials, however, only included patients treated with percutaneous coronary intervention (PCI), and evidence regarding complete revascularization with coronary artery bypass graft (CABG) surgery after culprit lesion-only PCI ('hybrid revascularization') is lacking. The CABG after PCI is an open, non-negligible therapeutic option, for patients with non-culprit left main and/or left anterior descending coronary artery disease where evidence in chronic coronary syndrome patients points in several cases to a preference of CABG over PCI. This valuable but poorly studied 'PCI first-CABG later' option presents, however, relevant challenges, mostly in the need of interrupting post-stenting dual antiplatelet therapy (DAPT) for surgery to prevent excess bleeding. Depending on patients' clinical characteristics and coronary anatomical features, either deferring surgery after a safe interruption of DAPT or bridging DAPT interruption with intravenous short-acting antithrombotic agents appears to be a suitable option. Off-pump minimally invasive surgical revascularization, associated with less operative bleeding than open-chest surgery, may be an adjunctive strategy when revascularization cannot be safely deferred and DAPT is not interrupted. Here, the rationale, patient selection, optimal timing, and adjunctive strategies are reviewed for an ideal approach to hybrid revascularization in post-acute coronary syndrome patients to support physicians' choices in a case-by-case patient-tailored approach.

Tracheostomy in Patients with Acute Myocardial Infarction and Respiratory Failure.

Patients with acute myocardial infarction (AMI) complicated by respiratory failure require antiplatelet regimens which often cannot be stopped and may increase bleeding from tracheostomy. However, there is limited available data on both the proportion of patients undergoing tracheostomy and the impact on antiplatelet regimens on outcomes. Utilizing the Vizient® Clinical Data Base, we identified patients ≥18 years admitted from 2015 to 2019 with a primary diagnosis of AMI and requiring invasive mechanical ventilation (IMV). We assessed for the incidence of patients undergoing tracheostomy, outcomes stratified by the timing of tracheostomy (≤10 vs >10 days), and the association between dual antiplatelet therapy (DAPT) use and in-hospital mortality. We identified 26 435 patients presenting with AMI requiring IMV. The mean (SD) age was 66.8 (12.3) years and 33.4% were women. The incidence of tracheostomy was 6.0% (n = 1573), and the median IMV time to tracheostomy was 12 days, 55.6% of which underwent percutaneous and 44.4% underwent open tracheostomy. Over 90% (n = 1424) underwent tracheostomy (>10 days) and had a similar mortality when compared to early (≤10 days) tracheostomy (22.5% vs 22.8%, P = 0.94). On the day of tracheostomy, only 24.7% were given DAPT, which was associated with a lower mortality than those not on DAPT (17.4% vs 23.7%, P = 0.01). After multivariable adjustment, DAPT use on the day of tracheostomy remained associated with lower in-hospital mortality (odds ratio 0.68; 95% confidence interval: 0.49-0.94, P = 0.02). Tracheostomy complications were not different between groups (P > 0.05), but more patients in the DAPT group required post-tracheostomy blood transfusions (5.6% vs 2.7%, P = 0.01). Approximately 1 in 20 intubated AMI patients requires tracheostomy. The lack of DAPT interruption on the day of tracheostomy but not the timing of tracheostomy was associated with a lower in-hospital mortality. Our results suggest that DAPT should not be a barrier to tracheostomy for patients with AMI.

Antithrombotic Stewardship: Evaluation of Platelet Reactivity-Guided Cangrelor Dosing Using the VerifyNow Assay.

Cangrelor may be used as a bridge when temporary interruption of dual antiplatelet therapy is necessary. However, the optimal dose and monitoring of cangrelor in patients remains unknown, especially in the setting of mechanical circulatory support (MCS). We conducted an observational, single-center, retrospective cohort study of patients who had percutaneous coronary intervention within 3 months and received cangrelor while admitted to any intensive care unit. The primary outcome was the incidence of any major adverse cardiovascular event. Secondary outcomes included VerifyNow platelet reactivity units (PRUs) measured while on cangrelor and any bleeding events while on cangrelor. A total of 92 patients were included. The most common reason for cangrelor use was in the periprocedural setting, with or without MCS (42%-45%), followed by NPO status (26%-28%) and MCS alone (22%-24%). The primary outcome of major adverse cardiovascular event occurred in 1 patient (1.1%). Of 92 patients, 77% had a P2Y12 level collected within 24 hours, and 89% of the cohort was able to achieve the goal P2Y12 PRU of <194. The median P2Y12 value within 24 hours of cangrelor initation was 115 PRU (40-168 PRU). We observed a bleed event rate of 23% (21/92). We found a standardized protocol of cangrelor dosing in critically ill patients who received a drug-eluting stent in the past 3 months to be successful in achieving a goal P2Y12 PRU. Although the optimal PRU remains unknown, cardiovascular clinicians may monitor these levels to help guide decisions regarding cangrelor management. Future randomized controlled trials should evaluate the optimal PRU threshold to balance risks of ischemia and bleeding.

P98 A CASE OF “RECURRENT” AORTIC VALVE STENOSIS

Abstract Clinical Case A 80–year–old man underwent coronary angiography in 2006 because of stable angina. There was chronic total occlusion of middle left anterior descending artery requiring percutaneous intervention. In 2009 he underwent coronary angiography for recurrent angina: a severe stent restenosis was treated with stenting in stent (DES in BMS). The patient was subsequently asymptomatic till 2018 when he complained of exertional dyspnea and angina. Stent patency and severe aortic valve stenosis (AVA 0.85 cm2) were documented. The patient underwent successful transcatheter aortic valve implantation and discharged with dual antiplatelet therapy (DAPT) (Asa 100 mg and Clopidogrel 75 mg). Clinical and echocardiographic follow–up was unremarkable (mean prosthetic gradient 17 mmHg, DVI=0.45). In July 2021 during a cardiological check the patient complained of bruising: ASA was discontinued. In February 2022 the patient suffered from an exertional angina. A dipyridamole stress–echocardiography failed to demonstrate inducible ischemia, although the patient experienced angina at the peak load step. Transthoracic echocardiogram (TTE) revealed high mean trans–prosthetic aortic gradient (52 mmHg, DVI=0.18). A trans–esophageal echocardiogram (TEE) showed reduced mobility of the thickened left coronary and non–coronary aortic prosthetic leaflets. In the hypothesis of prosthetic valve thrombosis, warfarin (INR range 2–3) was started after stopping clopidogrel. After three months a TTE showed normalized mean trans–prosthetic gradients (17 mmHg, DVI=0.5). When a 6 month–period of anticoagulant therapy was accomplished, warfarin was stopped and DAPT administered again. In September 2022 the patient complained of worsening dyspnea and chest pain on exertion. At TTE mean trans–prosthetic gradients (46 mmHg) was increased. A new TEE showed thickening of non–coronary and right coronary leaflets, suggestive of recurrent valve thrombosis. After stopping DAPT, warfarin was started again with good result (mean prosthetic gradient 12 mmHg, DVI=0.5). Conclusion Thrombosis of aortic valve prothesis is an infrequent event usually occurring in early post–implantation period. In our case it occurred four years after implantation following DAPT interruption. The likely initial prosthetic valve degeneration together with a simplification of DAPT may have had a causative role. Since the proved efficacy of warfarin and the limited experience of DOAC in this field, the patient was given warfarin sine die.

Thrombotic vs. Bleeding Events of Interruption of Dual Antiplatelet Therapy within 12 Months among Patients with Stent-Driven High Ischemic Risk Definition following PCI.

Background There is a paucity of real-world data regarding the clinical impact of dual antiplatelet therapy (DAPT) interruption (temporary or permanent) among patients at high ischemic risk. The aim of this study was to assess the risk of cardiovascular events after interruption of DAPT in high-risk PCI population. Methods This study used data from the Fuwai PCI registry, a large, prospective cohort of consecutive patients who underwent PCI. We assessed 3,931 patients with at least 1 high ischemic risk criteria of stent-related recurrent ischemic events proposed in the 2017 ESC guidelines for focused update on DAPT who were free of major cardiac events in the first 12 months. The primary ischemic endpoint was 30-month major adverse cardiac and cerebrovascular events, and the key safety endpoints were BARC class 2, 3, or 5 bleeding and net adverse clinical events. Results DAPT interruption within 12 months occurred in 1,122 patients (28.5%), most of which were due to bleeding events or patients' noncompliance to treatment. A multivariate Cox regression model, propensity score (PS) matching, and inverse probability of treatment weighting (IPTW) based on the propensity score demonstrated that DAPT interruption significantly increased the risk of primary ischemic endpoint compared with prolonged DAPT (3.9% vs. 2.2%; Cox-adjusted hazard ratio (HR): 1.840; 95% confidence interval (CI): 1.247 to 2.716; PS matching-HR: 2.049 [1.236–3.399]; IPTW-adjusted HR: 1.843 [1.250–2.717]). This difference was driven mainly by all-cause death (1.8% vs. 0.7%) and MI (1.3% vs. 0.5%). Furthermore, the rate of net adverse clinical events (4.9% vs. 3.2%; Cox-adjusted HR: 1.581 [1.128–2.216]; PS matching-HR: 1.639 [1.075–2.499]; IPTW-adjusted HR: 1.554 [1.110–2.177]) was also higher in patients with DAPT interruption (≤12 months), whereas no significant differences between groups were observed in terms of BARC 2, 3, or 5 bleeding. These findings were consistent across various stent-driven high-ischemic risk subsets with respect to the primary ischemic endpoints, with a greater magnitude of harm among patients with diffuse multivessel diabetic coronary artery disease. Conclusions In patients undergoing high-risk PCI, interruption of DAPT in the first 12 months occurred infrequently and was associated with a significantly higher adjusted risk of major adverse cardiovascular events and net adverse clinical events. 2017 ESC stent-driven high ischemic risk criteria may help clinicians to discriminate patient selection in the use of long-term DAPT when the ischemic risk certainly overcomes the bleeding one.

Management of Antithrombotic Therapy in Post Percutaneous Coronary Intervention Patient Undergoing Pericardiostomy due to Large Pericardial Effusion: A Case Report

Background : Stent thrombosis is a serious complication following percutaneous coronary intervention (PCI), and dual antiplatelet therapy (DAPT) is necessary to avoid it. Surgery, on the other hand, is a common cause for stopping DAPT. Because patients were exposed to the possibility of a major adverse cardiovascular event (MACE) when DAPT was stopped, this circumstance poses a clinical dilemma. Objective : This case report aimed to describe the management of antithrombotic therapy in post PCI patient requiring DAPT who underwent pericardiostomy. Case : A 69-year-old woman with large pericardial effusion without cardiac tamponade, breast cancer on chemo- therapy, heart failure stage C NYHA functional class II, chronic coronary syndrome post-DES implantation at proximal-mid LAD, and hypertension. The patient underwent pericardiotomy procedures five days after DAPT discontinuation. For the bridging therapy, continuous UFH administration was initiated at a dose of 18 IU/kg/hour after the cessation of DAPT. The UFH dose was adjusted to achieve activated partial thromboplastin time (APTT) 1.5 to 2.0 times the control value. The UFH was discontinued 6 hours before surgery. After surgery, UFH infusion was restarted 6 hours after the confirmation of hemostasis. The administration of UFH then continued until three days after DAPT was restarted. No complications were found during and after the pericar- diostomy. Conclusion : We reported an antithrombotic treatment strategy in a post PCI patient undergoing pericardiostomy with discontinuation of DAPT, which was successfully treated with UFH without any complication. The UFH has been widely used in perioperative settings as a bridging therapy during the interruption of DAPT and may be considered in this condition.

First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating.

Background: In the last decade, flow diversion (FD) has been established as hemodynamic treatment for cerebral aneurysms arising from proximal and distal cerebral arteries. However, two significant limitations remain—the need for 0.027” microcatheters required for delivery of most flow diverting stents (FDS), and long-term dual anti-platelet therapy (DAPT) in order to prevent FDS-associated thromboembolism, at the cost of increasing the risk for hemorrhage. This study reports the experience of three neurovascular centers with the p64MW-HPC, a FDS with anti-thrombotic coating that is implantable via a 0.021” microcatheter.Materials and methods: Three neurovascular centers contributed to this retrospective analysis of patients that had been treated with the p64MW-HPC between March 2020 and March 2021. Clinical data, aneurysm characteristics, and follow-up results, including procedural and post-procedural complications, were recorded. The hemodynamic effect was assessed using the O'Kelly–Marotta Scale (OKM).Results: Thirty-two patients (22 female, mean age 57.1 years) with 33 aneurysms (27 anterior circulation and six posterior circulation) were successfully treated with the p64MW-HPC. In 30/32 patients (93.75%), aneurysmal perfusion was significantly reduced immediately post implantation. Follow-up imaging was available for 23 aneurysms. Delayed aneurysm perfusion (OKM A3: 8.7%), reduction in aneurysm size (OKM B1-3: 26.1%), or sufficient separation from the parent vessel (OKM C1-3 and D1: 65.2%) was demonstrated at the last available follow-up after a mean of 5.9 months. In two cases, device thrombosis after early discontinuation of DAPT occurred. One delayed rupture caused a caroticocavernous fistula. The complications were treated sufficiently and all patients recovered without permanent significant morbidity.Conclusion: Treatment with the p64MW-HPC is safe and feasible and achieves good early aneurysm occlusion rates in the proximal intracranial circulation, which are comparable to those of well-established FDS. Sudden interruption of DAPT in the early post-interventional phase can cause in-stent thrombosis despite the HPC surface modification. Deliverability via the 0.021” microcatheter facilitates treatment in challenging vascular anatomies.

Perioperative dual antiplatelet therapy for patients undergoing spine surgery soon after drug eluting stent placement.

Background: Performing emergent spinal surgery within 6 months of percutaneous placement of drug-eluting coronary stent (DES) is complex. The risks of spinal bleeding in a “closed space” must be compared with the risks of stent thrombosis or major cardiac event from dual antiplatelet therapy (DAPT) interruption.Methods: Eighty relevant English language papers published in PubMed were reviewed in detail.Results: Variables considered regarding surgery in patients on DAPT for DES included: (1) surgical indications, (2) percutaneous cardiac intervention (PCI) type (balloon angioplasty vs. stenting), (3) stent type (drug-eluting vs. balloon mechanical stent), and (4) PCI to noncardiac surgery interval. The highest complication rate was observed within 6 weeks of stent placement, this corresponds to the endothelialization phase. Few studies document how to manage patients with critical spinal disease warranting operative intervention within 6 months of their PCI for DES placement.Conclusion: The treatment of patients requiring urgent or emergent spinal surgery within 6 months of undergoing a PCI for DES placement is challenging. As early interruption of DAPT may have catastrophic consequences, we hereby proposed a novel protocol involving stopping clopidogrel 5 days before and aspirin 3 days before spinal surgery, and bridging the interval with a reversible P2Y12 inhibitor until surgery. Moreover, postoperatively, aspirin could be started on postoperative day 1 and clopidogrel on day 2. Nevertheless, this treatment strategy may not be appropriate for all patients, and multidisciplinary approval of perioperative antiplatelet therapy management protocols is essential.

885 Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an uncommon cause of Acute Coronary Syndrome (ACS). Predisposing factors include fibromuscular dysplasia, connective tissue disease and systemic inflammatory conditions. There is predilection to female sex. Pregnancy associated (p-SCAD) has the worst clinical outcome- the cause of which is not entirely understood. We describe the case of a 34-year-old woman, at 14 weeks of pregnancy, who presented to Emergency Department with sudden onset of central chest pain and shortness of breath. No preceding triggers or cardiovascular risk factors were identified. ECG showed anterolateral ST segment elevation and she was haemodynamically unstable. She underwent emergency Coronary Angiogram that revealed SCAD of left main coronary artery (LMCA) / proximal left anterior descending artery (LAD) with TIMI flow 0. Percutaneous coronary intervention restored TIMI 3 flow. At 38+3 weeks she had an elective Caesarean section and underwent permanent contraception with bilateral salpingectomy. Our case is interesting as due to clinical instability, compromised haemodynamics and involvement of distal LMCA/ proximal LAD, intervention was preferred over conservative approach. Appropriate interventional strategies helped overcome technical difficulties and avoid complications. We addressed the use of pharmacy during pregnancy and lactation. Fortunately, she had no complications due to interruption of dual anti-platelet therapy at time of Caesarean section and pro-thrombotic post-partum period. She has minimal risk for p-SCAD recurrence due to permanent contraception. Our case highlights SCAD as an important differential in young women presenting with chest pain; early recognition is imperative as treatment differs from ACS.

Interruption of Dual Antiplatelet Therapy Within Six Months After Coronary Stents (from the Dual Antiplatelet Therapy Study)

The risk of major adverse cardiac and cerebrovascular events (MACCE) in subjects who interrupt temporarily or permanently thienopyridine therapy in the first 6 months after percutaneous coronary intervention (PCI) remains uncertain. In the dual antiplatelet therapy (DAPT) study subjects were enrolled within 72 hours of PCI and treated with aspirin and a thienopyridine for 12 months before being randomized to continued thienopyridine versus placebo. This analysis focuses on the 12-month period before randomization. Thienopyridine interruptions of greater than 24 hours, occurring in the first 6 months after PCI were evaluated. The incidence of MACCE and moderate or severe bleeding occurring within 12 months after PCI were compared between subjects with and without interruptions. Among 23,002 subjects, the incidence of interruption of thienopyridine was 5.1% (n = 1,173). Compared with subjects who adhered to treatment, subjects with an interruption had a higher incidence of MACCE (6.1% vs 4.3%, p = 0.005), death (2.2% vs 1.4%, p = 0.02), myocardial infarction (3.8% vs 2.7%, p = 0.03), and bleeding (3.1% vs 2.2%, p = 0.04) at 12 months. After adjusting for baseline characteristics, interruptions were associated with MACCE (adjusted odds ratio 1.3, 95% confidence interval 1.0, 1.7, p = 0.04) and had a borderline association with subsequent bleeding (adjusted odds ratio 1.4, 95% confidence interval 1.0, 2.0, p = 0.05). In conclusion, interruption of thienopyridine in the first 6 months after PCI occurs not infrequently and is associated with an increased risk of MACCE and subsequent bleeding between the time of interruption and 12 months after PCI.

How do cardiologists select patients for dual antiplatelet therapy continuation beyond 1 year after a myocardial infarction? Insights from the EYESHOT Post-MI Study.

BackgroundCurrent guidelines suggest to consider dual antiplatelet therapy (DAPT) continuation for longer than 12 months in selected patients with myocardial infarction (MI).HypothesisWe sought to assess the criteria used by cardiologists in daily practice to select patients with a history of MI eligible for DAPT continuation beyond 1 year.MethodsWe analyzed data from the EYESHOT Post‐MI, a prospective, observational, nationwide study aimed to evaluate the management of patients presenting to cardiologists 1 to 3 years from the last MI event.ResultsOut of the 1633 post‐MI patients enrolled in the study between March and December 2017, 557 (34.1%) were on DAPT at the time of enrolment, and 450 (27.6%) were prescribed DAPT after cardiologist assessment. At multivariate analyses, a percutaneous coronary intervention (PCI) with multiple stents and the presence of peripheral artery disease (PAD) resulted as independent predictors of DAPT continuation, while atrial fibrillation was the only independent predictor of DAPT interruption for patients both at the second and the third year from MI at enrolment and the time of discharge/end of the visit.ConclusionsRisk scores recommended by current guidelines for guiding decisions on DAPT duration are underused and misused in clinical practice. A PCI with multiple stents and a history of PAD resulted as the clinical variables more frequently associated with DAPT continuation beyond 1 year from the index MI.

Geographical Variations in Patterns of DAPT Cessation and Two-Year PCI Outcomes: Insights from the PARIS Registry.

Data on geographical variations in dual antiplatelet therapy (DAPT) cessation and the impact on outcomes after percutaneous coronary intervention (PCI) are limited. We sought to evaluate geographical patterns of DAPT cessation and associated outcomes in patients undergoing PCI in the United States versus Europe. Analyzing data from the PARIS registry, we studied 3,660 U.S. patients (72.9%) and 1,358 European patients (27.1%) that underwent PCI with stent implantation. DAPT cessation was classified as physician-recommended discontinuation, interruption (< 14 days), or disruption due to bleeding or noncompliance. The primary endpoint was 2-year major adverse cardiovascular events (MACE) defined as a composite of cardiac death, stent thrombosis, myocardial infarction, or target lesion revascularization. Cardiovascular risk factors were more common in the United States, whereas procedural complexity was greater in Europe. The incidence of 2-year DAPT discontinuation was significantly lower in U.S. versus European patients (30.7% vs. 65.6%; p < 0.001); however, rates of interruption (13.7% vs. 1.5%, p < 0.001) and disruption (17.7% vs. 5.1%, p < 0.001) were higher. DAPT discontinuation was associated with lower adjusted risk, whereas DAPT disruption was associated with greater risk for 2-year MACE, without interaction by region. After adjustment for baseline characteristics and DAPT cessation, 2-year MACE risk was not statistically different between regions (10.3% for Europe vs. 11.9% for U.S., adjusted hazard ratio 0.81, 95% confidence interval 0.65-1.01, p = 0.065). DAPT cessation patterns, along with clinical and angiographic risk, vary substantially between PCI patients in the U.S. versus Europe. Despite such differences, cardiovascular risk associated with DAPT cessation remains uniform.

Incidence of dual antiplatelet therapy interruption within 1 year after primary percutaneous coronary intervention in patients with acute ST elevation myocardial infarction

BackgroundAfter primary percutaneous coronary intervention (PPCI) in patients with acute ST elevation myocardial infarction (STEMI), dual antiplatelet therapy (DAPT) is recommended to continue for 1 year. Occasionally, DAPT interruption may...

Influence of Baseline Anemia on Dual Antiplatelet Therapy Cessation and Risk of Adverse Events After Percutaneous Coronary Intervention.

Anemia is a well-recognized risk factor for both bleeding and ischemic events after percutaneous coronary intervention (PCI). We sought to determine the impact of baseline anemia on dual antiplatelet therapy (DAPT) cessation patterns ≤2 years after PCI and the subsequent risk of clinical adverse events. PARIS (Patterns of Non-Adherence to Dual Anti-Platelet Regimen in Stented Patients) was a prospective multicenter observational registry of PCI-treated patients (n=5018). Anemia was defined as baseline Hb (hemoglobin) <12 g/dL for men and <11 g/dL for women. DAPT cessation modes included physician-recommended discontinuation, temporary interruption (≤14 days), and disruption due to bleeding or noncompliance. The primary end point was 2-year major adverse cardiovascular events (MACE), a composite of cardiac death, myocardial infarction, or target vessel revascularization. We identified 824 (18%) anemic and 4194 (82%) nonanemic patients. Anemic patients were older and had a higher rate of diabetes mellitus, hypertension, and prior PCI. DAPT interruption and disruption were significantly more common in anemic patients throughout 2 years after PCI, whereas physician-recommended discontinuation occurred more often in anemic patients during the first year after PCI and in nonanemic patients during the second year. The 2-year adjusted risks of MACE and Bleeding Academic Research Consortium 3 or 5 bleeding events were significantly higher in anemic patients. Compared with uninterrupted DAPT, disruption, but not interruption and physician-recommended discontinuation, was associated with a higher risk of myocardial infarction in nonanemic patients and a higher risk of both myocardial infarction and MACE in anemic patients. There was no significant interaction between anemia and risk of clinical outcomes associated with each DAPT cessation mode. Baseline anemia was associated with a significantly higher adjusted risk of MACE and major bleeding. Physicians more frequently recommend DAPT discontinuation to anemic patients during the first year, and to nonanemic patients during the second year after PCI. DAPT disruption was associated with a higher risk of MACE outcomes.

USE OF INTRAVENOUS CANGRELOR/DAPT BRIDGE THERAPY FOR POST-PCI PATIENTS UNDERGOING GASTROINTESTINAL SURGERY

Unavoidable early interruption of dual antiplatelet therapy (DAPT) after percutaneous intervention (PCI) often creates a clinical dilemma. Perioperative bridge therapy using intravenous cangrelor may offer a potential solution, although evidence for its use in non-cardiac procedures is limited. A

Patterns and Impact of Dual Antiplatelet Cessation on Cardiovascular Risk After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndromes

The aim of this study was to examine the patterns and clinical impact of differing modes of dual-antiplatelet therapy (DAPT) cessation after percutaneous coronary intervention (PCI) in patients presenting with and without acute coronary syndromes (ACS). The PARIS (patterns of nonadherence to antiplatelet regimens in stented patients) registry was a multicenter study of 5,018 patients who underwent PCI. DAPT cessation was categorized as physician-recommended discontinuation, interruption, or disruption. Overall rates of 2-year DAPT discontinuation did not differ between non-ACS and ACS patients (38.8% vs 37.2%, p = 0.252). ACS patients were less likely to interrupt DAPT (8.5% vs 10.7% p<0.001), but were more likely to disrupt DAPT (16.4% vs 11.9%, p<0001). Adverse events after DAPT cessation were highest after disruption, intermediate with discontinuation, and lowest with interruption across both groups. Disruption of DAPT predicted MACE in both ACS patients (hazard ratio [HR] 2.89 [1.88 to 4.45; p<0.001]) and non-ACS patients (HR 2.08 [1.29 to 3.35; p = 0.002]). Interruption of DAPT predicated MACE in ACS patients (HR 2.72 [1.35 to 5.48]) but not in non-ACS patients (HR 0.44 [0.14 to 1.40]; pinteraction≤0.01). In conclusion, the incidence of DAPT cessation mode differs by presentation with or without ACS. Physician guided DAPT discontinuation was the most common mode of DAPT cessation and appears to be safe across both groups. There were higher rates of adverse events associated with the interruption of DAPT in ACS patients.

Dual Antiplatelet Therapy Duration Determines Outcome After 2- But Not 1-Stent Strategy in Left Main Bifurcation Percutaneous Coronary Intervention

ObjectivesThe aim of this study was to investigate clinical outcomes after left main coronary artery (LM) bifurcation percutaneous coronary intervention (PCI) and the impact of the duration of dual antiplatelet therapy (DAPT) according to treatment strategy. BackgroundThere are limited data regarding the optimal PCI strategy for LM bifurcation lesions with new-generation drug-eluting stents. MethodsA patient-level pooled analysis of 5 nationwide multicenter registries was performed. Rates of target lesion failure, thrombotic adverse cardiovascular events, and their individual components at 3-year were analyzed. Subgroup analysis according to DAPT duration was performed. ResultsFrom 13,172 patients undergoing PCI with new-generation drug-eluting stents, a total of 700 patients were treated for LM bifurcation lesions, 567 with a 1-stent strategy and 133 with a 2-stent strategy. Rates of target lesion failure and target lesion revascularization were higher in the 2-stent group, driven mainly by complex lesion profiles. Risks for thrombotic adverse cardiovascular events and its components were comparable between the 2 strategies. Subgroup analysis showed that risks for target lesion failure and thrombotic adverse cardiovascular events in the 2-stent group were significantly higher than in the 1-stent group in those with DAPT interruption <1 year, while they were similar in those receiving DAPT maintenance ≥1 year. ConclusionsUp to 20% of patients who underwent LM bifurcation PCI eventually required a 2-stent strategy, which was as safe as a 1-stent strategy with the use of new-generation drug-eluting stents. Careful pre-emptive case selection as well as prolonged DAPT may be necessary when considering a 2-stent strategy in LM PCI given its higher rate of repeat revascularization and lesion failure than the 1-stent approach.

Intravenous Antiplatelet Therapy Bridging in Patients Undergoing Cardiac or Non-Cardiac Surgery Following Percutaneous Coronary Intervention.

The effect of perioperative bridging therapy on risks of ischemic cardiac events and major bleeding complications in patients on dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) remains undefined. We report on 60 consecutive patients between 2010 and 2017 who required cardiac (CS; n = 15) or non-cardiac (NCS; n = 45) surgeries following PCI at our institution. Short-acting intravenous (IV) antiplatelet (APT) bridging with eptifibatide, tirofiban and cangrelor were instituted after DAPT interruption. All patients were men with multiple atherosclerosis risk factors. An acute coronary syndrome indication (56.7%) was the most common PCI indication in the CS and NCS groups. Drug-eluting stents were used in 93.33% and 95.56% of the above groups, respectively. The median duration from PCI to CS and NCS were 11.17 and 18.25 months, respectively and 38.33% of all surgeries were performed within 6 months of the index PCI. Most patients were on background aspirin (83.33%) and clopidogrel (81.67%) and median duration of DAPT interruption was 7 days. Median duration of perioperative IV APT bridging was 3 days for CS and 5 days for NCS groups. In the CS group, two patients (13.33%) had non-fata myocardial infarction (MI), and four (26.67%) had clinically significant bleeding. No patients had perioperative stent thrombosis. In the NCS group, one patient (2.22%) had stent thrombosis; four (6.67%) had myocardial infarction, and five (11.11%) clinically significant bleeding. Despite using IV APT as bridging therapy during perioperative DAPT interruption in post-PCI patients, postoperative cardiac events and bleeding complications can still occur.

Acute and long-term outcomes after polytetrafluoroethylene or pericardium covered stenting for grade 3 coronary artery perforations: Insights from G3-CAP registry.

Covered stent (CS) implantation is considered a useful device in the setting of Grade III Coronary Perforation (G3CP), one of the most harmful PCI complication. However, data regarding efficacy of this device and clinical outcomes are still limited. From 1993 to 2015, among 97,779 patients from 9 European centres undergoing PCI, 224 patients had G3CP (0.23%), and 102 patients were managed with CS implantation (96 with PTFE, 6 with pericardium). Device oriented composite endpoint (DOCE), a composite of cardiac death, target lesion revascularization, and stent thrombosis (ST) in-hospital and at long term follow-up were evaluated. G3-CP perforations were successfully sealed with CS in 88 patients (86.3%) with need of intraprocedural pericardiocentesis in one-third of cases. Protamine as heparin reversal agent was administered in 36 (35%) of cases. The cumulative incidence of in-hospital DOCE were 16.6% (17/102): death 14.7%, TLR 2.9%, ST 3.9%. At long-term follow-up (mean 42 ± 38 months), DOCE rates occurred in 19.7%: death 7.4%, TLR 11%, and ST 6.2%. Indication to Dual Antiplatelet Therapy (DAPT) was lifelong in 20% of cases, 1 to 6 months in 22.5% and 12-months in 57.5% without differences in long-term DOCE before and after DAPT interruption (8.0 vs. 6.6%, respectively, P = 0.20). Use of CS was successful in sealing grade 3 coronary artery perforations in the majority of cases. Beside the high rate of clinical events at short and long-term, ST remains the leading cause of device failure.