Duration Of Antiplatelet Therapy Research Articles

Benefits and Risks of Prolonged Duration Dual Antiplatelet Therapy (Clopidogrel and Aspirin) After Percutaneous Coronary Intervention in High-Risk Patients With Diabetes Mellitus

The efficacy and safety of prolonged (>1-year) dual antiplatelet therapy (DAPT) duration in high-risk patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) remain unknown. All patients undergoing PCI at Fuwai hospital between January 2013 and December 2013 were prospectively enrolled into the Fuwai PCI registry. A total of 3,696 high-risk diabetics patients with at least one additional atherothrombotic risk factor were screened for inclusion. The primary efficacy outcome was the composite of all-cause mortality, myocardial infarction, or stroke. The median follow-up duration was 887 days. 69.8% of DM patients were on DAPT at 1 year without discontinuation. Based on multivariate Cox regression model and inverse probability of treatment weighting (IPTW) analysis, long-term (>1-year) DAPT reduced the risk of primary efficacy outcome (1.7% vs 4.1%; adjusted hazard ratio [adjHR]: 0.382, 95% confidence interval [CI]: 0.252 to 0.577; IPTW-HR: 0.362 [0.241 to 0.542]), as well as cardiovascular death and definite/probable stent thrombosis, compared with short-course (≤1-year) DAPT. Risk of the safety end point of clinically relevant bleeding (adjHR: 0.920 [0.467 to 1.816]; IPTW-HR: 0.969 [0.486 to 1.932]) was comparable between longer DAPT and shorter DAPT. A lower number of net clinical benefit adverse outcomes was observed with >1-year DAPT versus ≤1-year DAPT (adjHR: 0.471 [0.331 to 0.671]; IPTW-HR: 0.462 [0.327 to 0.652]), which appeared increasingly favorable in those with multiple atherothrombotic risk characteristics. In high-risk patients with DM receiving PCI who were event free at 1 year, DAPT prolongation resulted in significant reduction in the risk of ischemic events not offset by increase of clinically meaningful bleeding events, thereby achieving a net clinical benefit. Extending DAPT beyond the period mandated by guidelines seems reasonable in high-risk DM patients not deemed at high bleeding risk.

Abstract 14199: Long-term Impact of Baseline Anemia and Dual Antiplatelet Therapy Duration After Percutaneous Coronary Intervention

Background: Anemia is a known risk factor for future ischemic events and bleeding for patients with ischemic heart disease. However, there are little data about dual antiplatelet therapy (DAPT) duration for patients with anemia after percutaneous coronary intervention (PCI). Methods: From 2010 to 2013, a total of 1,470 patients who underwent PCI were investigated. We categorized the study population into four groups based on the DAPT duration and anemia (Hemoglobin <13g/dL for men and <12g/dL for women): Group A (non-anemia & ≤12m DAPT, n=521), Group B (non-anemia & >12m DAPT, n=501), Group C (anemia & ≤12m DAPT, n=226), and Group D (anemia & >12m DAPT, n=222). We evaluated major adverse cardiovascular and cerebrovascular events (MACCEs), defined as cardiac death, myocardial infarction, repeat target vessel revascularization, or stroke, and bleeding complication. Results: Even though anemic patients had more severe angiographic findings, such as three-vessel disease or diffuse long lesion, the DAPT duration was similar between anemia and non-anemia group. MACCEs occurred less frequently in Group B (16.9%) than Group A (24.7%), Group C (34.6%), and Group D (35.1%) (p<0.001) at 8 years. After multivariate analysis, with Group A as a reference, the adjusted hazard ratio for MACCEs was 0.711 (95% confidence interval [CI] 0.526-0.961, p=0.027) for Group B, 1.126 (95% CI 0.802-1.581, p=0.494) for Group C, and 0.995 (95% CI 0.706-1.405, p=0.980) for Group D. However, major bleeding occurred more frequently occurred in Group D (13.0%) than Group A (5.7%), Group B (7.5%), and Group C (11.2%) (p=0.035) at 8 years. Conclusions: Although extended DAPT showed reduced rate of MACCEs for non-anemic patients, it can be related with increased of major bleeding for anemic patients.

Impact of ischemic risk factors on long-term outcomes in patients with and without high bleeding risk

BackgroundThe current guidelines have recommended to shorten the dual antiplatelet therapy duration in patients at high bleeding risk (HBR) to minimize the bleeding complications. The impact of ischemic risk factors (IRF) on long-term ischemic events in patients with and without HBR after percutaneous coronary intervention remains unclear.MethodsThe study population comprised 1219 patients who were treated with everolimus-eluting stents between 2010 and 2011. The mean follow-up period was 2996 ± 433 days. HBR was defined as set by the Academic Research Consortium. IRF was defined as high-risk features of stent-driven recurrent ischemic events endorsed in the 2017 European Society of Cardiology Guidelines. Major bleeding was defined as the occurrence of Bleeding Academic Research Consortium type 3 or 5 bleeding. Primary ischemic events included myocardial infarction, definite stent thrombosis, and cardiac death.ResultsThe 1219 patients were divided into two groups: 614 patients at HBR (HBR group) and 605 patients at no HBR (non-HBR group). The rate of IRF patients was significantly higher in the HBR group than in the non-HBR group (81.4% versus 47.6%, P < 0.001). The cumulative rate of ischemic events in the HBR group was significantly higher in IRF patients than in non-IRF patients (21.0% versus 7.0%, log rank P < 0.001), whereas that in the non-HBR group was not significantly different between IRF and non-IRF patients (10.1% versus 6.3%, log rank P = 0.09).ConclusionsMore than 80% of HBR patients treated with everolimus-eluting stents were at IRF. A combination of HBR and IRF may increase the risk of long-term ischemic events.

Indirect evaluation of device-endothelialization with cardiac-CT after transcatheter closure of atrial septal defect: how long should antiplatelet therapy last postoperatively?

Abstract Background After transcatheter closure of atrial septal defect (ASD), it is still unclear about the in-vivo process of device-endothelialization in humans, which determines the duration of antiplatelet therapy. Based on contrast-uptake within device, cardiac-CT might have the potential to assess device-endothelialization indirectly. Purpose The study was conducted to investigate the status of device-endothelialization with cardiac-CT after transcatheter closure of ASD. Methods After more than 6 months of transcatheter ASD closure, cardiac-CT was performed in 119 patients (48M/71F; age: 46.7±14.4 years). According to contrast-uptake within device, complete or incomplete device-endothelialization was determined. In the latter, it was further divided into partial-endothelialization (with filling-defect) and no-endothelialization (without filling-defect). Multivariate logistic regression was used to determine the risk factors of incomplete device-endothelialization. In addition, device-endothelialization was analyzed grossly and histopathologically in 7 patients. Results During the implantation-period of 2.57±2.59 years, incomplete device-endothelialization was identified in 43.7% of patients (partial-endothelialization in 36 patients and no-endothelialization in 16 patients). Complete device-endothelialization occurred in 14.3% of patients during 0.5–1 year and 73.8% after one year. After 6-month antiplatelet therapy, migraine restarted in 15 patients with incomplete device-endothelialization and 3 patients with complete device-endothelialization. After one-year antiplatelet therapy, migraine was still detected in 4 of 15 patients with incomplete device-endothelialization. There was a significant association between high in-vivo device-thickness and incomplete device-endothelialization (P&amp;lt;0.001) after adjusted for confounding factors. Pathological findings from 7 patients corresponded well with cardiac-CT. Conclusions Cardiac-CT had the potential to evaluate the status of device-endothelialization after transcatheter closure of ASD and there was a good clinico-pathological correlation. Incomplete device-endothelialization was common postoperatively in humans and was associated with device-oversizing. Further research is required to determine the appropriate duration of antiplatelet therapy after device implantation. Figure 1 Funding Acknowledgement Type of funding source: Other. Main funding source(s): National Natural Science Foundation of China

One-Month Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention With Zotarolimus-Eluting Stents in High-Bleeding-Risk Patients.

Despite treatment guidance endorsing shortened dual antiplatelet therapy (DAPT) duration in high bleeding risk (HBR) patients after drug-eluting stents, limited evidence exists to support these recommendations. The present study was designed to examine the safety and effectiveness of 1-month DAPT duration following percutaneous coronary intervention with zotarolimus-eluting stents in HBR patients. Onyx ONE Clear was a prospective, multicenter, nonrandomized study evaluating the safety and effectiveness of 1-month DAPT followed by single antiplatelet therapy in HBR patients undergoing percutaneous coronary intervention with Resolute Onyx drug-eluting stents. The primary analysis of cardiac death or myocardial infarction between 1 month and 1 year was performed in the prespecified one-month clear population of patients pooled from the Onyx ONE US/Japan study and Onyx ONE randomized controlled trial. One-month clear was defined as DAPT adherence and without major adverse events during the first month following percutaneous coronary intervention. Among patients enrolled in Onyx ONE US/Japan (n=752) and Onyx ONE randomized controlled trial (n=1018), 1506 patients fulfilled one-month clear criteria. Mean HBR characteristics per patient was 1.6 with 44.7% having multiple risks. By 2 months and 1 year, respectively, 96.9% and 89.3% of patients were taking single antiplatelet therapy. Between 1 month and 1 year, the rate of the primary end point was 7.0%. The 1-sided upper 97.5% CI was 8.4%, less than the performance goal of 9.7% (P<0.001). Among HBR patients who were event free before DAPT discontinuation at 1 month, favorable safety and effectiveness through 1 year support treatment with Resolute Onyx drug-eluting stents as part of an individualized strategy for shortened DAPT duration following percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier NCT03647475.

Early vascular healing following bioresorbable-polymer sirolimus-eluting stent implantation in comparison with durable-polymer everolimus-eluting stent: sequential optical coherence tomography study

Abstract Background Orsiro ultrathin-strut bioresorbable-polymer sirolimus-eluting stent (BP-SES) might facilitate early vascular healing responses that seems to be associated with improved long-term clinical outcomes. We compared the early vascular healing responses to BP-SES and Xience durable-polymer everolimus-eluting stent (DP-EES) in patients with chronic coronary syndrome (CCS) using optical coherence tomography (OCT). Methods A total of 40 patients with CCS receiving OCT-guided PCI were included. 20 patients were assigned to BP-SES, and 20 to DP-EES. OCT was performed immediately after stent placement (post-procedure) and at 1 month follow-up. Struts were recorded as uncovered if any part was visibly exposed in the lumen or covered if a layer of tissue covered all reflecting surfaces. The incidence of intrastent thrombus (IS-Th) and irregular protrusion (IRP) were also assessed. Results At 1 month, the percentage of uncovered struts was significantly lower in the BP-SES compared with the DP-EES (2.8±1.6% vs. 5.8±1.8%, respectively; p&amp;lt;0.001), and that of malapposed struts was similar between both groups (2.5±3.1% vs. 2.4±2.2%; p=0.76). There were no differences in the incidence of IS-Th (65.0% vs. 55.0% at post-procedure; p=0.54, 30.0% vs. 35.0% at 1 month; p=0.75) and IRP (30.0% vs. 25.0% at post-procedure; p=0.74). IRP had completely resolved at 1 month in both groups. Conclusion Early vascular healing response to Orsiro BP-SES implantation was revealed in CCS patients at 1 month compared with Xience DP-EES. Orsiro BP-SES may have a potential to shorten the dual antiplatelet therapy duration. Funding Acknowledgement Type of funding source: None

Safety and Efficacy of 1-Month Dual Antiplatelet Therapy (Ticagrelor + Aspirin) Followed by 23-Month Ticagrelor Monotherapy in Patients Undergoing Staged Percutaneous Coronary Intervention (A Sub-Study from GLOBAL LEADERS)

Patients undergoing staged percutaneous coronary intervention (SPCI) are exposed to extended duration of antiplatelet therapy, and a novel aspirin-free antiplatelet regimen after SPCI should be specifically evaluated among these patients. This is a prespecified substudy of the GLOBAL LEADERS which is a randomized, open-label trial, comparing an experimental regimen of 1-month dual antiplatelet therapy (DAPT; ticagrelor and aspirin) followed by 23-month ticagrelor monotherapy to a reference regimen of 12-month DAPT followed by 12-month aspirin monotherapy. Patients were stratified according to whether or not SPCI was performed. The impact of the timing of SPCI on clinical outcomes was also investigated. Of 15,968 randomized patients, 1,651 patients underwent SPCI within 3 months. These patients with SPCI had a significantly higher risk of bleeding and ischemic endpoints than those without SPCI. In patients undergoing SPCI, the primary endpoint (composite of all-cause death or new Q-wave myocardial infarction at 2 years) and secondary safety endpoint (Bleeding Academic Research Consortium [BARC]-defined bleeding 3 or 5) were similar in the 2 regimens. However, in patients presenting with acute coronary syndrome (ACS), the experimental regimen reduced a risk of BARC 3 or 5 bleeding (1.8% vs 4.5%; HR 0.387; 95% CI 0.179 to 0.836; p = 0.016). In patients undergoing SPCI later than 10 days after index procedure, this risk reduction was still prominent (0.8% vs 2.3%; HR 0.321; 95% CI 0.116 to 0.891; p = 0.029). In conclusion, patients undergoing SPCI are at high risk and may need special attention from clinicians. In ACS patients undergoing SPCI, a novel aspirin-free antiplatelet regimen appears to be associated with a lower bleeding risk than with standard DAPT.

Dual antiplatelet therapy duration after percutaneous coronary intervention with drug-eluting stents: how short can we go?

Current guidelines recommend a duration of dual antiplatelet therapy (DAPT) with aspirin and oral P2Y<inf>12</inf> receptor inhibitors following percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) of 6 months for most patients with stable coronary disease and of 12 months for most patients with acute coronary syndromes. Large evidence from randomised clinical trials of shorter DAPT regimens after PCI with newer-generation DES is now emerging in heterogenous patient population not selected on the basis of high bleeding risk as well as in patients at high bleeding risk. The scope of this review is to provide an update on the benefits and harms of these short DAPT regimens and to discuss future directions in DAPT strategies after PCI with newer generation DES.

Short-term dual anti-platelet therapy decreases long-term cardiovascular mortality after transcatheter aortic valve replacement.

No data are available on extended dual anti-platelet therapy (DAPT) duration which may influence long-term prognosis (later than 1 year) after transcatheter aortic valve replacement (TAVR). Therefore, this study is aimed to evaluate whether discontinuing DAPT within 1 year had an impact on adverse events after TAVR. Using data from the OCEAN-TAVI registry, we assessed 1008 patients who survived the first year after TAVR with DAPT since discharge. Patients were divided into 'DAPT group' (n = 462), comprising patients who took DAPT at both discharge and 1 year, and 'stop-DAPT group' (n = 546), comprising patients who took DAPT at discharge and single anti-platelet therapy (SAPT) at 1 year. We compared the incidence of cardiovascular (CV) death, major and minor bleeding, and ischemic stroke later than 1 year after TAVR between the two groups. A total of 28 CV deaths were observed later than 1 year after TAVR. The stop-DAPT group had a significantly lower incidence of CV death than the DAPT group (1.8% vs. 4.9%, log-rank P = 0.029). Stop DAPT was associated with lower CV death later than 1 year of TAVR in Cox regression analysis (adjusted hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.20-0.99), and in analysis with inverse probability of treatment weighting method using propensity score (adjusted HR, 0.45; 95% CI, 0.20-0.98). Our study demonstrated that switching from DAPT to SAPT within 1 year of TAVR was significantly associated with a lower CV death later than 1 year after TAVR.

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).

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Tailoring Dual Antiplatelet Therapy for the Complex PCI Patient: Current Status and Perspectives.

Dual antiplatelet therapy (DAPT) duration in patients undergoing percutaneous coronary intervention (PCI) has long been considered a matter of controversy. Complex-PCI (C-PCI) is considered to be associated with an increased ischemic risk that tends to be greater with progressively higher procedural complexity. Thus, with a view to balance ischemic versus bleeding risks, high complexity of PCI intuitively represents an advocate of prolonged DAPT duration. However, the optimal DAPT strategy in this high ischemic risk subset of patients remains unclear, a fact that is exacerbated by the absence of a universal definition of C-PCI, resulting in a significant between-study heterogeneity. The aim of this review is to highlight the increased risks associated with C-PCI, compare long- versus short-term DAPT regimens regarding safety and efficacy endpoints as well as investigate outcomes in special C-PCI cohorts, such as patients with bifurcation, left main or chronic total occlusion lesions. Furthermore, controversial issues, such as antithrombotic regimens in C-PCI patients with atrial fibrillation, and future perspectives are addressed.

Dual Antiplatelet Therapy Duration in Medically Managed Acute Coronary Syndrome Patients: Sub-Analysis of the OPT-CAD Study.

Optimal dual antiplatelet therapy (DAPT) duration for medically managed acute coronary syndrome (ACS) (MMACS) patients is still unknown. We explored the efficacy and safety of ≥ 12-month DAPT among MMACS patients. In this sub-analysis of the optimal antiplatelet therapy for Chinese Patients with Coronary Artery Disease study (NCT01735305), clinical outcomes among MMACS patients were compared between the < 12-month and ≥ 12-month DAPT groups. The primary efficacy endpoint was a composite of cardiac death, myocardial infarction, and stroke. Safety endpoints included the Bleeding Academic Research Consortium (BARC) 2-5, BARC 3-5, and all bleeding events. Propensity score matching (PSM) was used to compare baseline characteristics between the < 12-month and ≥ 12-month DAPT groups. In this cohort of ACS patients (n = 10,016), MMACS patients (n = 2967) were less likely to use DAPT at 12 (31.64% vs. 67.47%, P < 0.0001) and 24 (13.82% vs. 18.71%, P < 0.0001) months and experienced more ischemic events at 12 (4.55% vs. 3.40%, P = 0.006) and 24 (6.88% vs. 5.08%, P = 0.0004) months than those treated with percutaneous coronary intervention (n = 7049). Among MMACS patients, the rate of primary efficacy endpoint occurring within the second year was significantly higher in the < 12-month DAPT group than in the ≥ 12-month group both before (2.88% vs. 1.60%, P = 0.040) and after (3.19% vs. 1.71%, P = 0.045) PSM. After PSM, no significant differences in all bleeding, BARC 2-5, and BARC 3-5 bleeding were found between the groups. MMACS patients with insufficient DAPT management experienced relatively more ischemic events. DAPT for at least 1year may be beneficial to this special population without significantly increasing the bleeding risks. ClinicalTrials.gov identifier, NCT01735305.

Antithrombotic Therapy for Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention.

1. What is the clinical question? What combination antithrombotic therapy is recommended for patients with atrial fibrillation with acute coronary syndrome or patients undergoing percutaneous coronary intervention? 2. What does the evidence say? Double therapy (DT) with clopidogrel and direct oral anticoagulants (specifically, dabigatran, rivaroxaban, and apixaban) is noninferior to warfarin-based therapies for most patients. Double therapy is noninferior to triple therapy (TT) and has less bleeding complications. 3. What is the take-home message for physicians? According to the latest guidelines by the ACC, AHA, ESC, and HRS, in patients with AF undergoing PCI, DT with DOACs (specifically dabigatran, rivaroxaban and apixaban) plus clopidogrel is acceptable. Patients undergoing PCI or with high ischemic risk may still benefit from TT for at least 1 month and up to 6 months before switching to DT. Currently, there is no specific guidance on long-term antiplatelet therapy in these patients. Duration of antiplatelet therapy, whether with DT or TT, should be based on current DAPT guidelines (depending on indication and type of intervention) and discussions with each patient's cardiologist.

Dual Antiplatelet Therapy Duration in Acute Coronary Syndrome Patients: The State of the Art and Open Issues.

Conflicting results have been reported so far in pooled analyses and studies evaluating the optimum duration of dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) patients. However, randomized clinical trials dedicated to this specific setting of higher thrombotic risk patients have only recently been completed, pointing at the noninferiority of a shorter strategy as compared to the traditional 12-month DAPT, furthermore allowing to reduce the risk of major bleeding complications. Therefore, a reconsideration of current clinical practice and guidelines should be certainly be advocated in light of the most recent updates, especially among ACS patients treated with percutaneous coronary intervention (PCI) and modern drug-eluting stents (DES). Our aim was to provide a comprehensive review of the available evidence on the optimal DAPT duration in ACS patients.

Antiplatelet strategies in ageing patients with acute coronary syndromes

Older patients who present with a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are at particular risk of recurrent ischaemic events, but also of bleeding complications.1 Choosing the optimal dual antiplatelet strategy for the ageing patient with ACS can thus present a dilemma in daily practice. Should dual antiplatelet therapy in an older patient include the less potent P2Y12 inhibitor clopidogrel, thus minimising bleeding risk, or should a more potent P2Y12 inhibitor such as ticagrelor or prasugrel be used to avoid recurrent ischaemic events? In addition, the ideal dual antiplatelet therapy duration for these patients remains unclear.

Nonculprit Lesion Myocardial Infarction Following Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome

BackgroundRecent emphasis on reduced duration and/or intensity of antiplatelet therapy following percutaneous coronary intervention (PCI) irrespective of indication for PCI may fail to account for the substantial risk of subsequent nontarget lesion events in acute coronary syndrome (ACS) patients. ObjectivesThe authors sought to examine the effect of more potent antiplatelet therapy on the basis of the timing and etiology of recurrent myocardial infarction (MI) or cardiovascular death following PCI for ACS. MethodsIn the TRITON-TIMI 38 study (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis In Myocardial Infarction 38), which randomized patients to prasugrel or clopidogrel, 12,844 patients with ACS received at least 1 stent. MI and cardiovascular death were categorized as: 1) procedural (related to revascularization); 2) definite or probable stent thrombosis (ST); or 3) spontaneous (non-ST or non–procedure-related). Median follow-up was 14.5 months. ResultsAmong the first events occurring within 30 days, 584 (69.0%) were procedural, 126 (14.9%) ST-related, and 136 (16.1%) spontaneous. After 30 days, 22 (4.7%) were procedural, 63 (13.5%) were ST-related, and 383 (81.8%) spontaneous. Prasugrel significantly reduced the incidence of MI or cardiovascular death for ST-related (1.0% vs. 2.1%; p < 0.001) and spontaneous events (3.9% vs. 4.8%; p = 0.012), with a directionally consistent numerical reduction for procedural events (4.4% vs. 5.1%; p = 0.078). Prasugrel increased spontaneous, but not procedural, major bleeding. ConclusionsLong-term potent antithrombotic therapy reduces de novo (spontaneous) atherothrombotic events in addition to preventing complications associated with stenting of the culprit lesion following ACS. In patients undergoing PCI for ACS, spontaneous events predominate after 30 days, with the later-phase cardiovascular benefit of potent dual antiplatelet therapy driven largely by reducing de novo atherothrombotic ischemic events. (Comparison of Prasugrel [CS-747] and Clopidogrel in Acute Coronary Syndrome Subjects Who Are to Undergo Percutaneous Coronary Intervention; NCT00097591)

Strategies to Prevent Ischemic Complications after Stent-assisted Coil Embolization of Cerebral Aneurysms.

There have been no delayed ischemic complications related to stent-assisted coil embolization (SACE) of cerebral aneurysms at our institution. We demonstrate our strategies for stent placement and postoperative management of antiplatelet therapy to reduce the risk of ischemic complications. We analyzed 57 cases of SACE retrospectively. In the procedure, an appropriate stent was selected and placed to fit the arterial wall without impeding on small arterial branches. Two different antiplatelet drugs, including clopidogrel, were used. Six to twelve months after surgery, follow-up angiography was performed to assess the safety of terminating antiplatelet therapy. In cases in which antiplatelet therapy was tapered, the two antiplatelet drugs were switched to clopidogrel alone, and it was subsequently tapered and finally discontinued. There were 49 cases of SACE in which postoperative antiplatelet therapy was tapered. Among these cases, antiplatelet therapy was discontinued in 35 cases. The mean duration of dual antiplatelet therapy was 10.6 ± 2.8 months, and the mean duration of total antiplatelet therapy was 15.0 ± 2.1 months. Three patients developed SACE-related ischemic stroke, which developed in the early phase after surgery in all. Antiplatelet therapy can safely be terminated in most cases of SACE. In order to reduce the risk of ischemic complications, stent selection, stent placement, and management of antiplatelet therapy should be performed appropriately. Furthermore, careful follow-up should be continued even after the termination of antiplatelet therapy.

Progression in cerebral microbleeds number after acute myocardial infarction: Harmful role of triple antithrombotic therapy

Cerebral microbleeds (CMB) is a predictive factor of intracerebral haemorrhage (ICH) and patients with CMB under antithrombotics are at higher risk of ICH. Thus, the impact of anticoagulants and/or antiplatelets on the occurrence of ICH and/or on new CMB development is a major issue. We aimed to evaluate the early progression at 3 months of CMB and their predictive factors in patients with acute myocardial infarction (AMI) treated with direct oral anticoagulant (DOA) or vitamin K antagonist (VKA). Prospective study from November 2016 to December 2018, including patients > 60 y hospitalized in intensive cardiac care unit for AMI. They underwent a first brain MRI (T2* gradient echo and SWI magnetic susceptibility image) < 72 hours after admission, and repeated 3 months after stenting. One hundred and eight patients (42 women and 66 men, mean age 77 years) were included. Among the patients with CMB (21%), 66 patients received a cerebral MRI at 3 months after AMI. An increase in CMB number was observed for 6% of patients. These patients were older than those without CMB progression (85 ± 5 vs. 75 ± 8 y, P = 0.016) and were more often treated by DOA or VKA at hospital discharge than patients with unchanged CMB number:OR = 15.6 [1.470–165.582]. In multivariate analysis, only discharge treatment with DOA or VKA was a predictive factor of CMB progression 3 M after AMI:OR = 13.8 [1.11–173.5]. No significant differences between the two groups with regard to CRUSADE and BLEEDING Risk haemorrhage scores were noted. Neither ICH nor ischemic stroke were observed. MRI-detected CMB was common and may even early increase after AMI. Our results highlight that the association of DOA or VKA with dual antiplatelet therapy at hospital discharge could be an independent risk factor of CMB progression. Larger population studies are needed to address antiplatelet therapy duration and dose of DOA as potential risk factors for CMB progression.

Impact of dual antiplatelet therapy duration on 1-year clinical outcomes in diabetic patients with acute coronary syndrome undergoing percutaneous coronary intervention: Insights from the real-world OPT-CAD study.

To investigate the optimal dual antiplatelet therapy (DAPT) duration for diabetic patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI). Diabetic patients are at high risk for ischemic and bleeding events when treated with antithrombotic agents after an ACS episode. This post hoc study analyzed DAPT duration and clinical outcomes in diabetic patients with ACS who underwent PCI in the Optimal antiPlatelet Therapy for Chinese patients with Coronary Artery Disease (OPT-CAD) registry. The primary outcome was patient-oriented composite endpoints (PoCE) at 12 months; it was defined as a composite of all-cause mortality, all myocardial infarction (MI), stroke, or any revascularization. The safety outcome was bleeding events. In total, 1,773 diabetic patients with ACS were enrolled and treated with PCI in the OPT-CAD study. Premature DAPT discontinuation before 12 months was an independent PoCE predictor in diabetic patients (hazard ratio = 1.33, 95% confidence interval: 1.02-1.74, p = .006). It was associated with a significantly higher risk of PoCE (17.3 vs. 11.2%, p = .014) in diabetic patients with high risk factors (age ≥ 65 years or history of cardiovascular events including MI, stroke, or peripheral artery disease), but this association was not observed in those without high risk factors (10.4 vs. 9.1, p = .554). No excess bleeding risk was found in patients who received 12-month DAPT compared with those who discontinued DAPT prematurely. Premature DAPT discontinuation before 12 months was associated with increased risk of clinical events in diabetic patients with ACS after PCI, particularly in those with high-risk profiles.