Dual Antiplatelet Therapy Score Research Articles

In-hospital mortality prediction using dual antiplatelet therapy score in coronavirus disease 2019

In-hospital mortality prediction using dual antiplatelet therapy score in coronavirus disease 2019

Outcomes in Patients Stratified by PRECISE-DAPT Versus DAPT Scores After Percutaneous Coronary Interventions

The optimal length of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remains debated. Current guidelines recommend individualized treatment with consideration of risk scores. We sought to evaluate the degree of agreement in treatment recommendations and the ability to predict ischemic and bleeding complications of the PRECISE-DAPT (predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy) and DAPT scores. Consecutive patients receiving 12 months of DAPT were grouped based on score treatment recommendation at the time of PCI: PRECISE-DAPT prolonged or shortened (PRECISE DAPT <25 vs ≥25) and DAPT prolonged or shortened (DAPT ≥2 vs <2). One-year ischemic and bleeding outcomes were compared for each group. In 451 patients, the PRECISE-DAPT and DAPT score recommendations were concordant in 56.7% of patients (Cohen's kappa for agreement of k = 0.139, 95% confidence interval 0.065 to 0.212). There was no difference in composite major adverse cardiovascular and cerebrovascular events between patients with high versus low PRECISE-DAPT or DAPT scores. In patients with a high PRECISE-DAPT score versus a low score, there was an increased incidence of 1-year all-cause mortality (2.13% vs 0%, p = 0.04) and an increase in bleeding (Bleeding Academic Research Consortium ≥3a: 17.0% vs 2.8%; p <0.001; Bleeding Academic Research Consortium 3b/c and 5: 8.5% vs 1.4%; p = 0.001). There were no differences in rates of mortality or bleeding for patients with high versus low DAPT scores. In conclusion, when applied at the baseline, the PRECISE-DAPT and DAPT scores frequently make discordant DAPT duration recommendations. The PRECISE-DAPT, but not the DAPT score, demonstrated associations with all-cause mortality and bleeding in patients prescribed 12 months of DAPT after PCI.

Provision of a DAPT Score to Cardiologists and Extension of Dual Antiplatelet Therapy Beyond 1 Year After ACS: Randomized Substudy of the Prospective Canadian ACS Reflective II Study

BackgroundExtension of dual antiplatelet therapy (DAPT) beyond 1 year after acute coronary syndrome is associated with a reduction in ischemic events but also increased bleeding. The DAPT score identifies individuals likely to derive overall benefit or harm from DAPT extension. We sought to evaluate the impact of providing the DAPT score to treating physicians on the decision to extend DAPT beyond 1 year after non–ST-segment elevation myocardial infarction. MethodsModerate to high-risk non–ST-segment elevation myocardial infarction patients were enrolled from July 2016 to May 2018 in 13 Canadian hospitals by 52 cardiologists. Participating cardiologists were randomly assigned 1:1 to receive their individual patients’ DAPT scores before the 1-year follow-up visit vs not receiving their patients’ DAPT scores. Rates of DAPT extension were compared among the randomized groups. ResultsAt 1 year, 370 of the 585 (63.2%) patients discharged on DAPT were receiving DAPT. Among patients on DAPT at 1 year, the median (25th, 75th percentile) DAPT score was 2 (1,3). DAPT was extended beyond 1 year in 36.2% randomly assigned to provision of DAPT score vs 35.7% in the control group (P = 0.93). In the subgroup of patients with DAPT score ≥ 2, DAPT extension was 49.5% in the DAPT score provision arm vs 40.4% in the control arm (P = 0.22); among patients with DAPT score < 2, DAPT termination was 78.6% in the DAPT score provision arm vs 70.6% in the control arm (P = 0.26) (P value for interaction = 0.1). ConclusionsIn this exploratory randomized trial, provision of the DAPT score to treating physicians had no impact on the duration of DAPT treatment beyond 1 year.

Saphenous Vein Graft Disease Interventions

AbstractIn the current era, coronary artery bypass grafting (CABG) is being increasingly performed using total arterial revascularization or a hybrid procedure of stenting of non-LAD disease and minimal access left internal mammary artery (LIMA) to LAD grafts, in order to minimize the need for vein grafts. Still, we encounter saphenous vein graft (SVG) disease, and it might require PCI, which often presents with unique challenges. The current favored strategy is to attempt PCI of the native coronary, if feasible, especially in long degenerated SVG disease, as it has shown better short- and long-term outcome. PCI is preferred over repeat CABG for early recurrent symptoms after CABG in patent LIMA graft and amenable anatomy patients. Balloon predilatation is not recommended unless delivery of an EPD or stent is not possible. Distal protection should be considered the standard of care for percutaneous coronary intervention (PCI) in most patients with older vein grafts, as periprocedural myocardial infarction and no reflow are the Achilles heel of SVG PCI. Intragraft vasodilators should be used liberally, even before balloon angioplasty/stenting. Avoid postdilatation, and usage of undersized but a longer stent length to reduce plaque extrusion through stent struts is preferred. Consider thrombectomy in lesions with a heavy thrombus burden. Keep activated clotting time on the higher side than in conventional PCI. Prolonged dual antiplatelet therapy (DAPT) based on the DAPT score is recommended. With all the precautions and care, we still need a fair wind in our favor to sail through the vein grafts disease.

Cancer Patients Have a Higher Risk of Thrombotic and Ischemic Events After Percutaneous Coronary Intervention.

This study sought to define the risk of stent thrombosis (ST) and myocardial infarction (MI) in cancer patients compared with noncancer patients after percutaneous coronary intervention (PCI). Cancer patients are considered to be at high thrombotic risk, but data on whether this is the case after PCI remain inconclusive. Cancer patients undergoing PCI at Mayo Clinic Rochester from January 1, 2003, to December 31, 2013, were identified by cross-linking institutional cancer and PCI databases and by propensity score matching to noncancer patients. The combined primary endpoint was all-cause mortality, MI, and revascularization rate at 5-year follow-up. Secondary endpoints were the individual primary endpoint components, cause of mortality, ST, and Bleeding Academic Research Consortium 2+ bleeding. The primary endpoint occurred in 48.6% of 416 cancer and in 33.0% of 768 noncancer patients (p<0.001). In competing risk analyses, cancer patients had a higher rate of noncardiac death (24.0% vs. 10.5%; p<0.001) and a lower rate of cardiac death (5.0% vs. 11.7%; p<0.001). Cancer patients had a higher rate of MI (16.1% vs. 8.0%; p<0.001), ST (6.0% vs. 2.3%; p<0.001), repeat revascularization (21.2% vs. 10.0%; p<0.001), and bleeding (6.7% vs. 3.9%; p=0.03). The most critical period for ST in cancer patients was in the first year after PCI. The dual antiplatelet therapy score was predictive of thrombotic and ischemic events in both groups. Cancer patients have a higher risk of thrombotic and ischemic events after PCI, identifiable by a high dual antiplatelet therapy score. These findings have important implications for antiplatelet therapy decisions.

The validation of the dual antiplatelet therapy score in East Asians receiving percutaneous coronary intervention with exclusively second generation drug-eluting stents.

We investigated whether the dual antiplatelet therapy (DAPT) score (DS) predicts clinical outcome in an East-Asian population that received exclusively second generation drug-eluting stent (DES). It is uncertain whether the DS could adequately risk stratify patients exclusively receiving second generation DES. From the Grand-DES registry, we evaluated patients who were treated with DAPT for at least 12 months and were event-free at 12 months after DES implantation. Patients were classified into two categories: high DS (≧2) (n=3,157); and low DS (<2) (n=5,226). The primary ischemic outcome was a composite of stent thrombosis and all myocardial infarction (MI), and the primary bleeding outcome was TIMI major or minor bleeding. A propensity score (PS)-matched analysis was done to correct for baseline differences between extended DAPT group and the conventional group. Among 8,383 subjects, the primary ischemic outcome occurred in 48 patients (0.6%) and the primary bleeding outcome in 49 patients (0.6%). High DS was associated with a higher incidence of ischemic events (ischemic outcome: 0.8% vs. 0.4%, for high vs. low DS, Log-rank p=.039), but not with any differences in bleeding events (Log-rank p=.734). In the PS-matched analysis, extended group was associated with lower risk of composite endpoint of MI, stent thrombosis, or cardiac death in only the high DS group (1.8% vs. 3.7%, Log-rank p=.004; hazard ratio 0.45, 95% confidence interval 0.27-0.76; p=.003 after adjustment). The DS was an adequate risk stratifier for future ischemic events in East Asians receiving exclusively second generation DES.

Validation of the DAPT score in large-scale consecutive and contemporary patients population in the real world

Dual antiplatelet therapy (DAPT) score emerged as a tool for quantification of ischemia and bleeding risks. However, there was discrepancy of the prediction ability of DAPT score in previous studies. We aimed to assess the utility of DAPT score in a large-scale cohort of consecutive percutaneous coronary intervention (PCI) patients. This study enrolled 9,114 patients who had undergone PCI at Fuwai Hospital in 2013, adhered to DAPT and were event-free within the first 12 months following PCI. The endpoints included primary ischemic endpoints (major adverse cardiovascular and cerebrovascular events, and myocardial infarction and/or stent thrombosis), and bleeding endpoint from 12 through 24 months after PCI. Patients were classified into low (score <2, n = 3,989) and high (score ≥2, n = 5,125) DAPT score groups. The incidence rates of primary ischemic endpoints and bleeding endpoint were similar between the two groups. Multivariable analysis demonstrated DAPT score not to be an independent predictor of primary ischemic endpoints or bleeding endpoint. Based on receiver operating characteristic curves analysis, the C-statistic of DAPT score for primary ischemic endpoints or bleeding endpoint did not achieve a significant extent. In this large-scale cohort of PCI patients, DAPT score did not discriminate the risks of ischemic and bleeding events.

Prospective external validation of PRECISE-DAPT score for prediction of bleeding and thrombosis after coronary stent implantation

Abstract Background Optimal duration of dual antiplatelet therapy (DAPT) after coronary stent implantation depends on bleeding and thrombotic risk in an individual patient. The PRECISE-DAPT score is recommended for adjusting of optimal DAPT duration. Purpose To assess external validation of PRECISE-DAPT score for prediction of out-of-hospital bleeding and thrombosis after coronary stent implantation in prospective manner. Methods We prospectively enrolled patients who underwent coronary stent implantation and received DAPT in our institution during June 2018 through December 2019. Out-of-hospital bleeding and thrombotic events were assessed for validation of PRECISE-DAPT score. Results Six hundred and two patients were enrolled. The mean age was 65.0±11.7 years and 28.2% were female. STEMI, NSTEMI/UA and chronic coronary syndrome were 24.4%, 22.6%, 53% respectively. Prevalence of prior bleeding was 6.3%. Mean follow-up period was 312±72 days. Bleeding events were 5.1%. High PRECISE-DAPT score (score ≥25) had significantly higher bleeding events (9.4% vs 2.4%, P-value &amp;lt;0.001), which were divided into major TIMI bleeding (3.4% vs 0.3%, P-valve 0.003) and minor TIMI bleeding (6.0% vs 2.2%, P-valve 0.014). MACE (CV death, MI, stroke) were 7% and significantly higher in high PRECISE-DAPT score (10.7% vs 4.6%, P-valve 0.004), compared with low PRECISE-DAPT score. Conclusions In real-world prospective study, high PRECISE DAPT score (score ≥25) is associated with high bleeding and thrombotic events. Because of increased both events in high PRECEISE-DAPT score, shortening DAPT duration requires physician final decision-making to balance future bleeding and thrombosis. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Siriraj grants for medical research and education, Faculty of Medicine Siriraj Hospital, Mahidol University

Utility of the dual antiplatelet therapy score to guide antiplatelet therapy: A systematic review and meta‐analysis

The dual antiplatelet therapy (DAPT) score, one of the first prediction tools to attempt to uncouple bleeding and ischemic risk following percutaneous coronary intervention, can help guide antiplatelet duration after coronary intervention. Evaluating the generalizability of the score is important to understand its utility in clinical practice. We conducted a systematic review and meta-analysis of studies that validated the DAPT score. A random effect meta-analysis was performed of ischemic and bleeding risk based on DAPT score. A secondary analysis assessed the risk of longer versus shorter P2Y12 inhibitor duration on ischemic and bleeding risk in randomized controlled trials of DAPT duration. We identified 10 patient cohorts involving 88,563 patients. Compared with a low DAPT score, a high DAPT score was associated with increased ischemic risk (RR: 1.62, 95% CI: 1.41-1.87) and reduced bleeding risk (RR: 0.80, 95% CI: 0.70-0.92). In three randomized trials of DAPT duration that contained information on the DAPT score, the relative risk of net adverse clinical events (combined ischemic and bleeding events) with longer duration of DAPT was 1.56 (95% CI: 0.77-3.19) for low DAPT score patients, and 0.86 (95% CI: 0.61-1.21) for high DAPT score patients (pinteraction = .14). In this large meta-analysis, the DAPT score consistently stratified bleeding and ischemic risk in opposing directions across several different study populations. More evaluation is needed to understand if the effect of longer DAPT duration on NACE is modified by the DAPT score in current practice.

Toward Brief Dual Antiplatelet Therapy and P2Y12 Inhibitors for Monotherapy After PCI.

The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention remains a controversial topic. The European Society of Cardiology and the American College of Cardiology/American Heart Association recommend at least 6 and 12months of DAPT after PCI in patients with stable coronary artery disease or acute coronary syndrome, respectively. Although prolonging DAPT duration reduces ischemic events, it is associated with higher rates of bleeding and possible fatal outcomes. The DAPT score can be an important tool to identify patients who may still benefit from prolonged therapy. Nevertheless, several recent randomized controlled trials showed that shortening DAPT duration from 12 to 1-3months reduces bleeding rates without significantly increasing ischemic event rates. These trials also suggested replacing acetylsalicylic acid (aspirin) with P2Y12 inhibitors after short-term DAPT. We review and compare past and present studies regarding DAPT and analyze the evidence favoring a short DAPT duration and the long-term single antiplatelet agent of choice.

A systematic review of the studies that evaluate the performance of the DAPT score.

The Dual Antiplatelet Therapy (DAPT) score was derived to determine which patients may benefit from prolonged DAPT therapy after 12months based on the balance between ischaemic and bleeding events. Several studies have attempted to validate the score with inconsistent findings. We conducted a systematic review of the studies that evaluated the DAPT score in PCI populations. A search was performed on MEDLINE and EMBASE and two independent reviewers reviewed the search results for study inclusion and extracted data from studies which met the inclusion criteria. Data are presented in tables and narrative synthesis was performed. A total of 13 studies were included in this review. The study designs included post hoc analysis of randomised trials, prospective cohorts, retrospective cohorts and a case-control study. In the derivation/validation study, the c-statistic for ischaemic and bleeding outcomes were 0.64/0.70 and 0.68/0.64, respectively. Among the validation studies, the C-statistics for composite outcomes ranged from 0.53 to 0.71 for ischaemic outcomes and 0.49 to 0.71 for bleeding outcomes. Only one study randomised patients with high DAPT score to different combinations of antiplatelet after 1year of DAPT and found that continuation of DAPT was associated with fewer deaths because of myocardial infarction, but more bleeding. While not designed for this purpose many studies have shown that the DAPT score has modest predictive value for ischaemic and bleeding outcomes. A prospective randomised controlled trial is needed to evaluate the clinical benefits of utilising the DAPT score in guiding continued DAPT therapy beyond 1year.

Impact of PRECISE-DAPT and DAPT Scores on Dual Antiplatelet Therapy Duration After 2nd Generation Drug-Eluting Stent Implantation.

Determining the optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is an important clinical issue. We evaluated the effects of ischemia (by DAPT score) and bleeding (by PRECISE-DAPT score), as well as the impact of DAPT duration, on clinical outcomes. From pooled analysis of four randomized clinical trials, 5131 patients undergoing second-generation DES implantation were randomized to short-duration (n=2575; ≤ 6months) or standard-duration (n = 2556; ≥ 12months) DAPT groups. This population was further divided into four subgroups according to PRECISE-DAPT (high bleeding risk ≥ 25) and DAPT (high ischemic risk ≥ 2) scores. Net clinical outcomes (1.3% vs. 1.3%; p = 0.89) and ischemic events (5.0% vs. 4.5%; p = 0.44) did not differ between the two duration groups, although bleeding events were more frequent in patients with standard-duration DAPT (0.4% vs. 0.9%; p = 0.04). Standard-duration DAPT was associated with fewer ischemic events (6.9% vs. 4.0%; p = 0.02) and no increase in bleeding events only among patients at low bleeding risk and high ischemic risk. The other groups show no differences in net clinical outcomes, ischemic events, or bleeding events according to DAPT duration. Compared with short-duration DAPT, standard-duration DAPT was associated with similar net clinical outcomes and ischemic events, but more bleeding events at 12months after second-generation DES implantation. However, standard-duration DAPT reduced ischemic events without increasing bleeding events among patients at low bleeding and high ischemic risk. When determining DAPT duration, considering both ischemic and bleeding risk can help optimize patient benefits. EXCELLENT (NCT00698607), RESET (NCT01145079), IVUS-XPL (NCT01308281), OPTIMA-C (NCT03056118).

Ischemic Versus Bleeding Outcomes After Percutaneous Coronary Interventions in Patients With High Bleeding Risk

Patients undergoing percutaneous coronary intervention (PCI) often have high-bleeding-risk (HBR) factors. Dual antiplatelet therapy (DAPT) further increases this risk of bleeding. We sought to compare clinical outcomes according to presence or absence of HBR factors in patients with elevated ischemic risk (DAPT score ≥ 2) undergoing PCI. We evaluated all patients undergoing PCI at MedStar Washington Hospital Center (January 2009 to July 2018) with DAPT score ≥2, which is associated with elevated risk of ischemic events. Patients were categorized as HBR group (HBR score ≥1) or low-bleeding-risk (LBR) group (HBR score = 0). Outcomes included major adverse cardiac events such as target vessel revascularization, stent thrombosis, death, and bleeding events at 30 days, 6 months, 1 year, and 2 years. The final cohort consisted of 7,499 patients: 3,949 patients had LBR features, and 3,550 patients had HBR features. The 2 groups were different at baseline, with HBR patients being older and having a higher prevalence of congestive heart failure and renal dysfunction than the LBR group. The mean DAPT score was 2.96±1.1 for the LBR group and 3.7±1.4 for the HBR group (p <0.001). During follow-up at 30 days, 6 months, and 1 and 2 years, the rates of target vessel revascularization and stent thrombosis were not significantly different between the 2 groups. Bleeding events and all-cause mortality were significantly more frequent in the HBR group than in the LBR group. In conclusion, patients undergoing PCI often have pre-existing risk factors that predispose them to ischemic and bleeding complications. Prolonged duration of DAPT to mitigate ischemic events could lead to a disproportionate increase in bleeding events, especially in HBR patients.

DAPT Score and the Impact of Ticagrelor Monotherapy During the Second Year After PCI

ObjectivesThis study assessed the ability of the dual-antiplatelet therapy (DAPT) score in stratifying ischemic and bleeding risk in a contemporary percutaneous coronary intervention (PCI) population. BackgroundThe DAPT score is recommended by guidelines as a tool to stratify ischemic and bleeding risk. Its utility in contemporary PCI is unknown. MethodsThe study studied patients in GLOBAL LEADERS (A Clinical Study Comparing Two Forms of Anti-platelet Therapy After Stent Implantation) who were free of major ischemic and bleeding events and adhered to antiplatelet strategy during the first year after PCI. The primary ischemic endpoint was the composite of myocardial infarction or stent thrombosis. The primary bleeding endpoint was Bleeding Academic Research Consortium type 3 or 5. Outcomes from 12 to 24 months after PCI were compared according to the DAPT score. ResultsOf 11,289 patients that were event-free after the first year, 6,882 and 4,407 patients had low (<2) and high (≥2) DAPT scores, respectively. Compared with a low DAPT score, patients with a high DAPT score had a higher rate of the composites of myocardial infarction or stent thrombosis (0.70% vs. 1.55%; p < 0.0001). The rate of Bleeding Academic Research Consortium type 3 or 5 bleeding was 0.54% and 0.30% in the low and high DAPT score groups, respectively (p = 0.058). The effect of ticagrelor versus aspirin monotherapy on primary ischemic and bleeding endpoints during the second year were no different among the 2 groups. ConclusionsThe DAPT score can stratify ischemic but not bleeding risk in a contemporary PCI population during the second year. The score did not provide additional value for selection of antiplatelet strategy beyond the first year.

P10 A possible link between sarcopenia and major bleeding risk among patients with atrial fibrillation treated with oral anticoagulation undergoing coronary stenting

Abstract Background/Introduction In patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with stent implantation, oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT) increases the risk of bleeding. The PRECISE-DAPT (P-DAPT) and DAPT scores were created to predict increased bleeding versus ischemic risk in patients undergoing DAPT. However, not much information is available on predicting bleeding risk associated with OAC concomitant with DAPT in patients with AF treated with coronary stents. Physical frailty or sarcopenia is considered an emerging predictor for bleeding in AF patients. Purpose To investigate the relationship between skeletal muscle mass and major bleeding risk in AF patients undergoing PCI and subsequent OAC and DAPT. Methods A total of 1,234 consecutive patients after PCI using newer-generation drug eluting stents were evaluated. An anti-thrombotic regimen without OAC was given to 1,077 patients, whereas OAC was required in 157 patients (12.7%) including AF (n = 96). The P-DAPT, DAPT, and HAS-BLED scores were calculated for each of the patients. Any out-of-hospital major bleeding events were identified based on BARC criteria during a median follow-up of 2.9 years. The fat-free mass index (FFMI; kg/m2) was calculated to evaluate skeletal muscle mass as follows: (7.38 + 0.02908 × urinary creatinine (mg/day)) / (height squared (m2)). A Cox proportional hazards model was used to test the significance of the FFMI and these risk scores as predictors of major bleeding, defined as BARC 3 or 5 events in AF patients. The receiver operating characteristic curve (ROC) analyses were used to examine the predictive ability of the FFMI and these scores to identify patients with major bleeding events. Results Major bleeding events were observed in 9 (9.3%) patients. Major bleeding was associated with a lower FFMI (hazard ratio [HR] 0.53; 95% confidence interval [CI] 0.36-0.79; p = 0.002), and higher P-DAPT score (HR, 1.07; 95% CI, 1.02-1.11; p = 0.003), but not with the DAPT (HR, 0.71; 95% CI, 0.45-1.12; p = 0.147) and the HAS-BLED score (HR, 1.00; 95% CI, 0.48-2.09; p = 0.990). In the non-OAC cohort, major bleeding was related to a higher P-DAPT score (HR, 1.05; 95% CI, 1.02-1.07; p &amp;lt; 0.0001), but the FFMI (HR, 0.89; 95% CI, 0.73-1.09; p = 0.265) and the DAPT score were not correlated. C-statistics for major bleeding events were 0.82 (95% CI, 0.71-0.93, p = 0.001) for the FFMI and 0.79 (95% CI, 0.68-0.90, p = 0.004) for the P-DAPT score. Conclusions Assessment of the FFMI for screening sarcopenia is useful to predict major bleedings specifically in patients with AF undergoing coronary stenting. Both the FFMI and P-DAPT could successfully predict major bleedings in AF patients after PCI. Whether novel bleeding risk scores combined with measuring body composition adequately identify high risk patients needs to be validated.

Meta-analysis of studies examining the external validity of the dual antiplatelet therapy score.

The dual antiplatelet therapy (DAPT) score is meant to aid clinicians choose the DAPT duration but attempts to examine the external validity of the DAPT score and its decision tool have reported mostly disappointing results. Our aim was to perform a meta-analysis of all available data on the external validity of the DAPT score. We conducted a meta-analysis of studies that examined the external validity of the DAPT score/its decision tool. Seven studies (77274 patients) were included. Follow-up ranged from 6 to 24 (median 18) months. Overall, high (≥2) DAPT score was associated with increased risk for myocardial infarction (MI)/stent thrombosis (ST) [odds ratio (OR) 1.54, 95% confidence interval (CI) 1.41-1.69; P < 0.01], and lower risk for bleeding (OR 0.84, 95% CI 0.73-0.97; P = 0.01). In the high DAPT score stratum, extended (12-24 months), as compared to standard (6-12 months) DAPT duration was associated with a reduction in the risk for MI/ST (OR 0.67, 95% CI 0.48-0.94; P = 0.02), and no difference in the risk for bleeding (OR 1.04, 95% CI 0.65-1.66; P = 0.88), while in the low DAPT score stratum, extended DAPT duration was associated with no difference in the risk for MI/ST (OR 1.04, 95% CI 0.76-1.43; P = 0.80), and an increased risk for bleeding (OR 1.58, 95% CI 1.15-2.15; P < 0.01). This first meta-analysis of studies examining the external validation of the DAPT score and its decision tool, our results suggest that the DAPT score is useful both for stratifying post-percutaneous coronary intervention patients into risk strata for future ischaemic and bleeding events as well aiding in choosing the optimal DAPT duration for the individual patient.

Long-Term Efficacy of Extended Dual Antiplatelet Therapy After Left Main Coronary Artery Bifurcation Stenting

Limited data exist on the long-term efficacy of extended dual antiplatelet therapy (DAPT) after left main coronary artery (LMCA) bifurcation stenting. This study investigated the long-term clinical outcomes associated with long-term DAPT after LMCA bifurcation stenting. Using data from the multicenter KOMATE and COBIS registries, we analyzed 1,142 patients who received a drug-eluting stent for a LMCA bifurcation lesion and who experienced no adverse events for 12 months after the index procedure. Patients were divided into 2 groups: DAPT >12 months (n = 769) and DAPT ≤12 months (n = 373). The primary end point was major adverse cardiovascular events (MACEs), as a composite of cardiac death, myocardial infarction, stroke, and stent thrombosis, over 5 years of follow-up. We further performed propensity score adjustment for clinical outcomes. DAPT >12 months afforded a lower MACE rate than DAPT ≤12 months (2.3% vs 5.4%, adjusted hazard ratio [HR] 0.37; 95% confidence interval [CI] 0.19 to 0.71; p = 0.003). The use of DAPT for >12 months was an independent predictor of a reduced likelihood of MACEs (HR 0.34; 95% CI 0.17 to 0.67; p = 0.002). A DAPT score ≥2, chronic kidney disease, and age >75 years were significant independent predictors of MACEs. In subgroup analysis, the use of DAPT for >12 months consistently resulted in better clinical outcomes across all subgroups, especially among patients with ACS, compared with the use of DAPT for ≤12 months. In conclusion, an extended duration of DAPT reduces MACE rates after LMCA bifurcation stenting.

P1932Predictors of DAPT use in patients beyond 1 year post myocardial infarction: Insights from the TIGRIS observational study

Abstract Background International guidelines vary in their recommendations for dual antiplatelet therapy (DAPT) use beyond 1 year post-myocardial infarction (MI). Purpose To identify predictors of DAPT use in patients ≥1 year post-MI prior to the publication of the DAPT score and the 2017 European Society of Cardiology (ESC) guidelines for DAPT in coronary artery disease. Methods TIGRIS (NCT01866904) was a prospective, multi-center (369 centers in 25 countries), observational study of patients 1 to 3 years post-MI between June 2013 and November 2014. We performed a multivariable logistic regression analysis to identify independent predictors of DAPT use at 396 days post-MI (365 + 31 days overrun period to allow intended DAPT discontinuation at 1 year). Patients on oral anticoagulation were excluded. Results Of 8464 patients enrolled (mean age 66 years, women 24%, ST-elevation MI 53%), 40% were on DAPT at 396 days post-MI (Figure). In the subset of patients on DAPT at 396 days post-MI, aspirin was combined with clopidogrel in 84%, prasugrel in 12%, and other antiplatelet agents in 4%. DAPT use at 396 days post-MI was independently associated with geographic region, age, PCI for the index MI, and a history of multivessel disease or angina (Table). Several variables included in the DAPT score and ESC guideline recommendations (diabetes, second prior MI, hypertension, peripheral artery disease, heart failure, smoking, and renal insufficiency) were not independent predictors of DAPT use at 396 days. Independent predictors of DAPT @396 days Variable at enrolment Patients Odds ratio (95% CI) P-value Region: Europe 3813 Reference group 0.01 North America 923 1.65 (0.56, 4.86) Latin America 1084 2.55 (1.19, 5.47) Asia and Australia 2644 3.01 (1.42, 6.36) Age &lt;65 years 3274 1.15 (1.04, 1.28) 0.005 PCI for index MI 6925 2.08 (1.82, 2.38) &lt;0.0001 Multi-vessel disease 5598 1.37 (1.24, 1.52) &lt;0.0001 History of angina 829 1.46 (1.24, 1.71) &lt;0.0001 DAPT use at 396 days post-MI by region Conclusion During the study period, DAPT use ≥1 year post-MI was prevalent and appeared to be influenced by regional practices. Further research is needed to determine whether the DAPT score and the 2017 ESC guidelines for dual antiplatelet therapy have changed long-term DAPT use practices. Acknowledgement/Funding AstraZeneca AB, Södertälje, Sweden

PREDICTORS OF DAPT USE IN PATIENTS BEYOND 1 YEAR POST MYOCARDIAL INFARCTION: INSIGHTS FROM THE TIGRIS OBSERVATIONAL STUDY

International guidelines vary in their recommendations for dual antiplatelet therapy (DAPT) use beyond 1 year post-myocardial infarction (MI). In the current analysis, we sought to identify predictors of DAPT use in patients ≥1 year post-MI prior to publication of the DAPT score and the most recent iterations of international guidelines for the use of DAPT in the management of patients with MI. TIGRIS (NCT01866904) was a prospective, multi-center (369 centers in 25 countries), observational study of patients 1 to 3 years post-MI between June 2013 and November 2014. We performed a multivariable logistic regression analysis to identify independent predictors of DAPT use at 396 days post-MI (365 days plus a 31-day overrun period to allow intended DAPT discontinuation at 1 year). Patients on oral anticoagulation or on treatment with ticagrelor were excluded. Of 8464 patients enrolled (mean age 66 years, women 24%, ST-elevation MI 53%, prior MI 10%, multivessel disease 66%), the index MI was managed with a percutaneous coronary intervention in 82% of patients, coronary artery bypass grafting in 7%, and medically in 11%. The prevalence of DAPT use was 78% at the time of hospital discharge and 40% at 396 days post-MI. There was significant variability in practice patterns of DAPT use post-MI across the different geographical regions (Figure). In the subset of patients on DAPT at 396 days post-MI, aspirin was combined with clopidogrel in 84%, prasugrel in 12%, and other antiplatelet agents in 4%. DAPT use at 396 days post-MI was independently associated with geographic region, age, use of PCI for the index MI, and a history of multivessel disease or angina (Table). Several variables included in the DAPT score and addressed in international guideline recommendations for the use of antiplatelet therapies (e.g. diabetes, second prior MI, hypertension, peripheral artery disease, heart failure, smoking, and renal insufficiency) were not independent predictors of DAPT use at 396 days. DAPT use declined from hospital discharge to 1 year post-MI. Overall, DAPT use ≥1 year post-MI was prevalent and appeared to be influenced by regional practices. Further research is needed to determine how the DAPT score and international guidelines have affected long-term DAPT use practice patterns.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

P840Predicting outcome in patients with symptomatic coronary artery disease: A comparison of available risk assessment scores

Abstract Introduction Thromboischemic and bleeding events are rare but potentially life-threatening complications after percutaneous coronary intervention (PCI). Consequently, duration of dual antiplatelet therapy (DAPT) after coronary stent implantation might be altered due to bleeding or thromboischemic risk. Various risk assessment models have been established to predict adverse events in patients with symptomatic coronary artery disease (CAD). The aim of the present study was to compare available scoring systems based on their performance identifying high-risk patients with symptomatic CAD. Methods and results 1469 patients were included (n=730 stable CAD and n=739 acute coronary syndrome (ACS)). GRACE 2.0, CALIBER, PREDICT-STABLE, PARIS MB, PARIS CTE and DAPT scores were calculated in appropriate patient subgroups. All patients were followed-up for 360 days for all-cause death (ACD), myocardial infarction (MI), ischemic stroke (IS) and bleeding. The primary combined endpoint (CE) consisted of ACD, MI and/or IS. Secondary endpoints were defined as single occurrence of either ACD, MI, IS, or bleeding. Strong discrimination performance for ACD (AUC=0.82) and IS (AUC=0.84) could be shown for PARIS-MB and CALIBER score, respectively. For ACD, good discrimination performance was found for GRACE (AUC=0.79), CALIBER (AUC=0.71), PARIS-CTE (AUC=0.71) and PREDICT-STABLE (AUC=0.70) score, respectively. For CE and bleeding, we could demonstrate good discrimination performance for GRACE (AUC=0.71) and CALIBER (AUC=0.76) score. Figure 1 Conclusions In short-term follow-up, several risk assessment models show strong to good discrimination performance for major adverse cardiovascular events. These prediction models might be used to adjust duration of DAPT in patients with symptomatic CAD. Acknowledgement/Funding DFG, KFO-274, SFB-TRR 240