Premature Discontinuation Of Dual Antiplatelet Therapy Research Articles

Effect of dual antiplatelet therapy prolongation in acute coronary syndrome patients with both high ischemic and bleeding risk: insight from the OPT-CAD study.

In current clinical practice, controversy remains regarding the clinical benefits of prolonged dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) patients facing high risks of both ischemia and bleeding ("bi-risk") following percutaneous coronary intervention (PCI). This study aimed to investigate the feasibility of identifying a group of bi-risk ACS patients after PCI using the OPT-BIRISK criteria, emphasizing extended DAPT treatment safety and efficacy beyond 12 months in these bi-risk ACS after PCI in real-world conditions. This analysis compared extended DAPT and single antiplatelet therapy (SAPT) at 12-24 months in ACS patients undergoing PCI complicated with both ischemic and bleeding risk as defined by OPT-BIRISK criteria without premature DAPT discontinuation before 9 months or major clinical adverse events within 12 months. This was a post hoc analysis of the Optimal antiPlatelet Antiplatelet Therapy for Chinese Patients with Coronary Artery Disease (OPT-CAD) study. The main research outcome was the incidence of ischemic events within 12-24 months, which was determined as a composite of stroke, myocardial infarction, and cardiac death events. Through propensity score matching (PSM), groups were balanced. For the external validation of the OPT-BIRISK criteria to identify a bi-risk ACS patient, ischemic events, BARC 2, 3, 5 bleeding events, and BARC 3, 5 bleeding events at 5 years were analyzed. The total number of ACS patients analyzed in this analysis was 7,049, of whom 4,146 (58.8%) were bi-risk patients and 2,903 (41.2%) were not. The frequency of ischemic events was significantly different between the two groups at 5 years (11.70% vs. 5.55%, P < 0.001), and the incidence of BARC 2,3,5 bleeding was significantly higher in the bi-risk group (6.90% vs. 4.03%, P < 0.001) than in the non-bi-risk group. Among the bi-risk patients without any clinical adverse events within 12 months that underwent extended DAPT treatment (n = 2,374, 75.7%) exhibited a lower risk of stroke at 12-24 months (1.10% vs. 2.10%, P = 0.036) relative to those that underwent SAPT (n = 763, 24.3%), while bleeding risk did not differ significantly between these groups. PSM cohort analysis results were consistent with those of overall group analyses. In conclusion, the findings showed that using the OPT-BIRISK criteria could help physicians identify ACS patients at a high risk of developing recurrent ischemia and bleeding episodes after PCI. Compared to antiplatelet monotherapy, a strategy of extended DAPT may offer potential benefits in lowering the risk of stroke without carrying a disproportionately high risk of serious bleeding problems among these patients who were event-free after a year of DAPT.

Prevalence of adverse events during ticagrelor versus clopidogrel treatment and its association with premature discontinuation of dual antiplatelet therapy in East Asian patients with acute coronary syndrome.

Clinical evidence raises the issues regarding the high risk of adverse events and serious bleeding in East Asian patients receiving standard-dose ticagrelor treatment. We sought to evaluate the association between adverse events and their associations with premature discontinuation of dual antiplatelet therapy (DAPT). We enrolled East Asian patients presented with acute coronary syndrome who took DAPT with 90-mg ticagrelor (n = 270) or 75-mg clopidogrel (n = 674). During 1-month treatment, antiplatelet effect was evaluated with the VerifyNow P2Y12 assay, and the occurrence of Bleeding Academic Research Consortium (BARC) bleeding and modified Medical Research Council (mMRC) dyspnea was assessed with the dedicated questionnaire. During 1-month follow-up, patients on ticagrelor showed the higher risks of bleeding (any BARC type: 45.6% vs. 23.6%; odds ratio [OR], 2.71 and BARC 1 or 2 type: 45.2% vs. 22.1%; OR, 2.90, respectively) and dyspnea (26.3% vs. 13.6%; OR, 2.25) compared with those on clopidogrel. In a receiver-operating characteristics curve analysis to predict bleeding risk, ticagrelor showed a lower cutoff of low platelet reactivity (LPR) (P2Y12 reaction unit [PRU] ≤ 20) than clopidogrel (PRU ≤ 110). Early occurrence of bleeding episode was significantly associated with LPR phenotype (OR, 2.68), not type of P2Y12 inhibitor. In multivariate analysis, type of P2Y12 inhibitor (ticagrelor vs. clopidogrel: OR, 2.19) and bleeding episode (OR, 2.94) were independent predictors for dyspnea occurrence. During 1-year follow-up, DAPT with ticagrelor showed a higher risk of premature discontinuation compared to DAPT with clopidogrel (27.8% vs. 4.7%; adjusted HR, 8.84), which risk appeared frequent during the first month (14.4%) during DAPT with ticagrelor. Early occurrence of bleeding and dyspnea synergistically increased a risk of DAPT non-adherence, irrespective of type of P2Y12 inhibitor. This analysis is the first evidence to show the different cutoff of low platelet reactivity during the reversible (ticagrelor) versus irreversible P2Y12 inhibitor (clopidogrel). Early occurrence of bleeding and dyspnea is very common during standard-dose ticagrelor treatment in East Asian patients, which show a close association with premature DAPT discontinuation. [https://www.clinicaltrials.gov], identifier[NCT046 50529].

Adherence of ticagrelOr in real world patients with aCute coronary syndrome: The AD-HOC study.

BackgroundDual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist is the cornerstone of therapy in patients with acute coronary syndrome (ACS). Adherence to medical therapy is an important issue, as premature DAPT discontinuation increases the risk of new ischemic events. The aim of the present observational prospective multicenter study was to evaluate in the real-world incidence and discontinuation patterns of ticagrelor during the first 12 months after ACS.MethodsWe analyzed 431 ACS patients, discharged with ticagrelor, by 7 Italian centers. The primary end-point was the incidence of cessation of ticagrelor up to 12 months from the index event.ResultsDefinitive ticagrelor cessations occurred in 52 patients (12.1%), of which 35 were discontinuations (clinically driven) and 17 disruptions (due to acute events). Temporary cessation occurred in 14 cases (3.3%). Age ≥ 80 years and anticoagulant therapy were independent predictors of premature discontinuation. Bleeding occurred in 74 patients, of which 25 suffered a BARC ≥ 2 bleeding event. Bleeding were more frequent in female sex (27.0% vs 17.2%, p-value 0.049) and in patients with a history of bleeding (8.1% vs 2.9%, p-value 0.035).ConclusionsOur study found that the adherence to DAPT with ticagrelor after an ACS is still an important issue, premature discontinuation occurred mainly in fragile patients, like elderly, who suffered a previous bleeding or underwent previous percutaneous coronary intervention.

Prognosis impact of ticagrelor vs clopidogrel based DAPT discontinuation after acute coronary syndrome. Insights from the multicenter CREA ARIAM Andalucia registry

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): The study project was financially supported by a non-conditional grant by Astrazeneca. Background/Introduction Premature cessation of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) has been associated with increased risk of major adverse cardiovascular events (MACE) Purpose To assess the relationship between premature DAPT discontinuation versus therapy continuation and outcomes in ACS patients discharged on ticagrelor or clopidogrel. Methods Prospective, observational, multicentre all-comers registry of ACS patients who were intended to receive 12-month DAPT with ticagrelor or clopidogrel. Adherence was defined by the medication possession ratio metric (MPA, proportion of days of medication supply within a time interval). Categories for DAPT cessation included: physician-recommended discontinuation, brief interruption (invasive procedures), or disruption due to non-compliance or because of bleeding. Fully-adjusted Cox models with time-varying covariates to account for informative censoring, were used to examine the effect of DAPT cessation on MACE (a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, definite stent thrombosis, or target-lesion revascularization). Moderation analysis was also performed to assess for potential exposure-adherence interaction. Results Among 2070 patients included (mean age 63 years, 73% men), 150 (7.3%) prematurely discontinued DAPT, median (IQR) 214 (101-236) days. Significantly more clopidogrel than ticagrelor users discontinued medication (9.5% vs 5%, respectively; P = .001), though timing of cessation was similar in both groups. At 1 year, MPR was slightly higher, but not significantly different, in the clopidogrel group than in the ticagrelor group (70±30 vs 64±29; P = .06). Overall, physician-guided discontinuation and bleeding were the main reasons for DAPT cessation. These were observed with a similar rate in both groups, while non-compliant disruption was more common among ticagrelor- than clopidogrel-treated patients (8% vs 2%, respectively; P for trend .04). After adjustments, DAPT cessation was associated with significantly increased risk of MACE (adjusted HR 2.94; 95% CI 1.82 – 4.74; P &amp;lt; .0001), regardless of the P2Y12 inhibitor (P interaction = 0.665). Non-compliance related cessation resulted in higher risk of MACE (HR 6.04, 95%CI 2.15 – 16.95; P = .001). Conclusion(s) Overall, approximately 7% of patients discontinued DAPT. Early cessation of either ticagrelor- or clopidogrel-based DAPT portended to a near 3-fold increased risk of MACE. Disruption due to non-compliance resulted in higher risk for ischemic events. These data warrant efforts to focus on patient education in subgroups at high risk of non-compliance.

Dual Antiplatelet Therapy Discontinuation, Platelet Reactivity, andAdverse Outcomes After Successful Percutaneous Coronary Intervention.

The purpose of this study was to assess the extent to which the association between premature dual antiplatelet therapy (DAPT) discontinuation and excess risk of thrombotic events varies according to the reason and timing of DAPT discontinuation and whether high on-treatment platelet reactivity (HPR) influences the risk of thrombotic events after premature DAPT discontinuation. DAPT after percutaneous coronary intervention (PCI) suppresses platelet reactivity, and HPR on clopidogrel after PCI is associated with an increased risk of thrombotic events. ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) was a prospective, multicenter registry of 8,582 patients successfully treated with coronary drug-eluting stents that assessed HPR on clopidogrel. For patients who discontinued aspirin or clopidogrel at any time during the study, the reasons for discontinuation were systematically categorized. Planned DAPT discontinuation occurred within 2 years in 3,203 (37.3%) patients. One thousand four hundred eighteen (16.5%) patients discontinued DAPT for unplanned reasons, including surgery or trauma (n=768 [8.9%]), patient nonadherence (n=321 [3.7%]), bleeding complications (n=264 [3.1%]), and drug allergy or hypersensitivity (n=113 [1.3%]). Unplanned but not planned DAPT discontinuation was associated with an increased risk of a major adverse cardiac event (MACE, defined as the composite of cardiac death, myocardial infarction, or stent thrombosis); with highest risk within 3months after PCI (adjusted HR: 7.65, 95% CI: 2.77-21.10 vs adjusted HR: 2.47, 95% CI: 1.70-3.58 for unplanned DAPT discontinuation≥3weeks after PCI). MACE risk after DAPT discontinuation was not moderated by HPR (Pinteraction=0.91). In this large-scale all-comers registry, premature DAPT discontinuation for unplanned reasons occurred in approximately 1 of 6 patients after DES implantation and was associated with a markedly increased risk of MACEs. (Assessment of Dual AntiPlatelet Therapy With Drug Eluting Stents [ADAPT-DES]; NCT00638794).

Adherence to dual antiplatelet therapy after coronary stenting: A study conducted at two Vietnamese hospitals.

Introduction: Adherence to dual antiplatelet therapy (DAPT) is critical after drug-eluting stent(DES) placement. We aimed to assess patient’s knowledge, rates of DAPT adherence, trends in DAPT use over time, and patient‐level factors associated with nonadherence in the patient with acute coronary syndrome (ACS). Methods: ACS patients who received one or more DES between May and September 2018from two hospitals in Vietnam and used DAPT after stent placement were eligible for a direct interview to assess patient’s knowledge on disease and DAPT. Telephone interviews were conducted one, three, and six months following discharge. Nonadherence was defined as premature discontinuation of DAPT. Factors related to nonadherent patients were analyzed using the chi-square test. Results: Of the 200 patients identified, 154 (77%) participated. Of the ten questions related to knowledge, the mean score of correct answers was 8.2 ± 2.3, and 71.7% had good knowledge.Adherence to DAPT was high at one month (94.2%) but declined by three months (44.2%) and then by six months (46.8%). Aspirin adherence was 99.3%-100% throughout. Three factors associated with nonadherence of DAPT following DES placement by six months included: rural location, linactive occupation, and inadequate knowledge on disease and DAPT (p <0.05). Conclusion: DAPT adherence is high at one month but is suboptimal at three and six months.Factors associated with the nonadherence of DAPT will be helpful in the planning of patient education strategies.

Premature Discontinuation of Dual Antiplatelet Therapy After Coronary Stenting in Veterans: Characteristics and Long-Term Outcomes.

BackgroundPremature discontinuation of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention is related to higher short‐term risks of adverse outcomes. Whether these risks persist in the long‐term is uncertain.Methods and ResultsWe assessed all patients having percutaneous coronary intervention with coronary second‐ or first‐generation drug‐eluting stents in the Veterans Affairs healthcare system between 2006 and 2012 who were free of major ischemic or bleeding events in the first 12 months. The characteristics of patients who stopped DAPT prematurely (1–9 months duration), compared with >9 to 12 months, or extended duration (>12 months) were assessed by odds ratios (ORs) from multivariable logistic models. The risk of adverse clinical outcomes over a mean 5.1 years in patients who stopped DAPT prematurely was assessed by hazard ratios (HRs) and 95% CIs from Cox regression models. A total of 14 239 had second‐generation drug‐eluting stents, and 8583 had first‐generation drug‐eluting stents. Premature discontinuation of DAPT was more likely in Black patients (OR, 1.54; 95% CI, 1.40–1.68), patients with greater frailty (OR, 1.04; 95% CI, 1.03–1.05), and patients with higher low‐density lipoprotein cholesterol, and less likely in patients on statins (OR, 0.87; 95% CI, 0.80–0.95). Patients who stopped DAPT prematurely had higher long‐term risks of death (second‐generation drug‐eluting stents: HR, 1.35; 95% CI, 1.19–1.56), myocardial infarction (second‐generation drug‐eluting stents: HR, 1.46; 95% CI, 1.22–1.74), and repeated coronary revascularization (second‐generation drug‐eluting stents: HR, 1.24; 95% CI, 1.08–1.41).ConclusionsPatients who stop DAPT prematurely have features that reflect greater frailty, poorer medication use, and other social factors. They continue to have higher risks of major adverse outcomes over the long‐term and may require more intensive surveillance many years after percutaneous coronary intervention.

Impact of extended dual antiplatelet therapy on long-term prognosis in patients with acute coronary syndrome complicated with anemia: A sub-analysis of the real-world OPT-CAD study.

To evaluate the impact of extended dual antiplatelet therapy (DAPT) beyond 12 months on long-term prognosis in acute coronary syndrome (ACS) patients complicated with anemia undergoing percutaneous coronary intervention (PCI). Anemia is frequent among ACS patients and is associated with increased risk of adverse clinical outcomes. A total of 6,953 patients were enrolled from the Optimal anti Platelet Therapy for Chinese patients with Coronary Artery Disease (OPT-CAD) study. A landmark analysis comparing extended DAPT versus single antiplatelet therapy (SAPT) at 12-24 months were performed in anemia patients without premature discontinuation of DAPT before 9months and major clinical adverse events within 12 months. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of all-cause death, myocardial infarction, and stroke. Patients with anemia (n=1,728) had higher rates of MACCE, all-cause mortality, and BARC type 2, 3, 5 bleeding (p < .05) compared to those without anemia (n=5,225). Anemia patients received extended DAPT (n=1,010) were associated with a lower risk of stroke (0.3% vs. 1.8%; HR, 0.14; 95% CI, 0.03-0.71; p=.018) compared to those received SAPT (n=342). The rates of MACCE and all revascularization were lower in patients with extended DAPT, but the differences were not statistically significant. Risk of all-cause mortality and bleeding were comparable between the two groups. Extended DAPT beyond 12 months may reduce the incidence of stroke without increasing the risk of bleeding in anemic ACS patients who tolerate 12-month DAPT.

Adherence to prophylactic dual antiplatelet therapy in patients with acute coronary syndrome – A study conducted at a Saudi university hospital

ObjectivesThe aim of this study was to evaluate patients’ self-reported adherence to dual antiplatelet therapy (DAPT) and determine the factors associated with premature discontinuation of DAPT. MethodsThe cross-sectional interview-based study was conducted among adult outpatients who visited the outpatient department of King Khalid University Hospital, Cardiac Center in Riyadh, Saudi Arabia, over a period of 3 months from May to July of 2016. Medication adherence was assessed using the Self-efficacy for Appropriate Medication Use Scale (SEAMS), which is composed of 13 items with a 3-point Likert scale. ResultsA total of 192 patients participated in the study. The majority of the participants were male (82.1%), and the mean age was 55.66 ± 10.80 years. More than 84% (84.4%) of the patients reported that they were “confident” in taking several medications each day. The minimum and maximum SEAMS scores were 22 and 39, respectively, with the mean score being 30.8 ± 3.5. Almost all patients had moderate scores and adherence; only one patient got a score of 39. Among sociodemographic characteristics, only health insurance and income were significantly associated with the medication adherence score (p < 0.05). ConclusionsStudy results concluded that patients had a moderate level of adherence towards DAPT in Saudi Arabia, however Patient education on DAPT is essential to improve adherence to medication treatment. More effective intentions and education methods should be developed to improve long-term DAPT adherence.

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.

Therapeutic strategies for ischemic heart disease

Abstract The original concept of onco-cardiology was developed as cardiotoxicity associated with anticancer treatment; however, recently, the number of cases in which atherosclerotic cardiovascular diseases coexist with malignant diseases has increased, and increasing attention is being paid to the relationship between malignant diseases and cardiovascular diseases, based on the long-term surveillance of cancer survivors. Several studies have described a high risk of cardiovascular disease events in cancer survivors. Similarly, a history of cardiovascular disease also confers higher risk incident cancer. Thus, this relationship has been drawing attention as a new aspect of onco-cardiology. The most troublesome issue in cancer patients is antithrombotic therapy. The clinical benefits of using dual anti-platelet therapy (DAPT) with aspirin and P2Y12 inhibitors in patients with ischemic heart diseases (acute coronary syndrome (ACS) or after percutaneous coronary intervention [PCI]) has been well established; premature discontinuation of DAPT increases the risk of adverse coronary events in those patients. In this joint symposium by JSMO and the Japanese Circulation Society(JCS), we present therapeutic strategies for ischemic heart disease.

Meta-analysis of drug eluting stents compared with bare metal stents in high bleeding risk patients undergoing percutaneous coronary interventions.

To determine the efficacy and safety of drug-eluting stents (DESs) and bare metal stents (BMSs) when used with short or tailored dual antiplatelet therapy (DAPT) in high bleeding risk (HBR) patients. DES have been shown to reduce target lesion revascularization (TLR) as well as stent thrombosis (ST) compared to BMS in patients undergoing percutaneous coronary intervention (PCI). However, patients at HBR continue to receive BMS given the fear of bleeding or ST from premature discontinuation of DAPT in patients receiving DES. We performed a meta-analysis of randomized controlled trials by performing systematic search for studies comparing DES with BMS in HBR patients using PUBMED, MEDLINE, and Cochrane Central, reported until March 1, 2018. Three randomized controlled studies met the inclusion criteria with total of 4,460 patients; 50% received DES. Major adverse cardiovascular event (MACE); composite of death, myocardial infarction (MI), and TLR, at 1 year was significantly lower (RR = 0.63, 95% CI 0.50-0.80) in DES group compared to BMS. This difference was primarily driven by lower TLR (RR = 0.46, 95% CI 0.35-0.61) in DES group. Definite or probable ST (RR = 0.59, 95% CI = 0.32-1.08) and major (RR = 0.94, 95% CI = 0.74-1.20) bleeding were similar. DES was associated with lower MACE without increased risk of bleeding or ST compared to BMS when used with short or tailored DAPT in patients with HBR.

Mid-term outcomes after percutaneous interventions in coronary bifurcations

BackgroundThe optimal treatment of patients undergoing percutaneous coronary interventions (PCI) for lesions located at coronary bifurcations is still debated. MethodsData on 5036 consecutive patients who underwent PCI on coronary bifurcation at 17 major coronary intervention centers between January 2012 and December 2014 were collected. ResultsFollow-up at a median 18 months (IQR 11-28) was available for 4506 patients (89%). Major Adverse Cardiac Events (MACE) occurred in 395 patients (8.8%): cardiac death in 152 (3.4%), myocardial infarction, excluding periprocedural, in 156 (3.5%) and stent thrombosis in 110 cases (2.4%).At multivariable Cox regression, left ventricular ejection fraction ≤30% (P < 0.001), bail-out stenting (beyond a planned strategy of either single or double stenting) (P < 0.001), admission for an acute coronary syndrome (P < 0.001), age >66 years (P < 0.001), multivessel disease (P < 0.001) and diabetes (P < 0.001) were independently associated with MACE. Sensitivity analysis identified premature discontinuation of dual antiplatelet therapy (DAPT) (P < 0.001) and side branch (SB) lesion length ≥9 mm (P < 0.05) as additional independent predictors of MACE. ConclusionsBeyond traditional risk factors, multivessel disease, the length of the SB lesion, “bail-out” stenting and premature DAPT discontinuation are independent predictors of mid-term MACE after PCI of coronary bifurcations. This highlights the importance of a carefully planned PCI strategy and adequate therapy adherence to improve the clinical outcomes in these patients. Clinical trial registrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT01967615.

“Bringing on the light” in a complex clinical scenario: Optical coherence tomography–guided discontinuation of antiplatelet therapy in cancer patients with coronary artery disease (PROTECT-OCT registry)

Cancer patients with recently placed drug-eluting stents (DESs) often require premature dual antiplatelet therapy (DAPT) discontinuation for cancer-related procedures. Optical coherence tomography (OCT) can identify risk factors for stent thrombosis such as stent malapposition, incomplete strut coverage and in-stent restenosis and may help guide discontinuation of DAPT. We conducted a single-center prospective study in cancer patients with recently placed (1-12 months) DES who required premature DAPT discontinuation. Patients were evaluated with diagnostic coronary angiogram and OCT. Individuals with appropriate stent strut coverage, expansion, apposition, and absence of in-stent restenosis or intraluminal masses were considered low risk and transiently discontinued DAPT to allow optimal cancer therapy. Patients who did not meet all these criteria were considered high risk and underwent further endovascular treatment when appropriate and bridging with low-molecular weight heparin. The incidence of adverse cardiovascular events was assessed after the procedure and at 12 months. A total of 40 patients were included. Twenty-seven patients (68%) were considered low risk by OCT criteria and DAPT was transiently discontinued. Thirteen patients (32%) were considered high risk with one or more OCT findings: uncovered stent struts (4 patients, 10%); stent underexpansion (3 patients, 8%); malapposition (8 patients, 20%); in-stent restenosis (2 patients, 5%). The high-risk patients with uncovered stent struts and malapposition underwent additional stent dilatation. There were no cardiovascular events in the low-risk group. One myocardial infarction occurred in the high-risk group. Fourteen non-cardiac deaths were registered before 12 months due to cancer progression or cancer therapy. OCT imaging allows identification of low-risk cancer patients with DES placed who may safely discontinue DAPT and proceed with cancer-related surgery or procedures.

A Retrospective Study Showing the Extent of Compliance With Perioperative Guidelines in Patients With Coronary Stents With Regard to Double Antiplatelet Therapy

(Abstracted from J Clin Anesth, 33:179–184, 2016) In patients with obstructive coronary artery disease, therapy using percutaneous coronary intervention with bare-metal stent and drug-eluting stent placement has been found to be very effective despite challenges to the perioperative management of these patients. Dual antiplatelet therapy (DAPT), specifically a P2Y12 receptor inhibitor (clopidogrel, ticagrelor, prasugrel, orticlopidine) in addition to aspirin, is used to prevent coronary artery in-stent thrombosis, caused by complete and premature discontinuation of DAPT.

Cangrelor Bridge Therapy for Gastroduodenal Biopsy

Dual antiplatelet therapy (DAPT) is the key for secondary prevention of acute coronary syndromes and percutaneous coronary intervention with stent placement. Premature discontinuation of DAPT can result in an increase in cardiac ischemic events and death. If early interruption of DAPT for urgent procedures or surgery is necessary, then ischemic and bleed risks must be balanced with bridging therapy. To date, no medications have a Food and Drug Administration indication for antiplatelet bridge therapy. We present a case of a woman with a history of gastrointestinal bleeding on DAPT for a drug-eluting stent who received cangrelor as bridge therapy prior to gastroduodenal biopsy.

Prospective and Systematic Analysis of Unexpected Requests for Non-Cardiac Surgery or Other Invasive Procedures during the First Year after Drug-Eluting Stent Implantation

PurposeUnexpected requests for non-cardiac surgery requiring discontinuation of dual antiplatelet therapy (DAPT) frequently occur in daily clinical practice. The objectives of this study were to evaluate prevalence, timing and clinical outcomes of such unexpected requests for non-cardiac surgery or other invasive procedures during the first year after drug-eluting stents (DESs) implantation.Materials and MethodsWe prospectively investigated the prevalence, timing and clinical outcomes of unexpected requests for non-cardiac surgery or other procedures during the first year after DESs implantation in 2117 patients.ResultsThe prevalence of requested non-cardiac surgery or invasive procedures was 14.6% in 310 requests and 12.3% in 261 patients. Among 310 requests, those were proposed in 11.3% <1 month, 30.0% between 1 and 3 months, 36.8% between 4 and 6 months and 21.9% between 7 and 12 months post-DES implantation. The rates of actual discontinuation of DAPT and non-cardiac surgery or procedure finally performed were 35.8% (111 of 310 requests) and 53.2% (165 of 310 requests), respectively. On multivariate regression analysis, the most significant determinants for actual discontinuation of DAPT were Endeavor zotarolimus-eluting stent implantation with 3-month DAPT (OR=5.54, 95% CI 2.95-10.44, p<0.001) and timing of request (OR=2.84, 95% CI 1.97-4.11, p<0.001). There were no patients with any death, myocardial infarction, or stent thrombosis related with actual discontinuation of DAPT.ConclusionThose unexpected requests with premature discontinuation of DAPT were relatively common and continuously proposed during the first year following DES implantation. No death, myocardial infarction or stent thrombosis occurred in patients with actual discontinuation of DAPT.

ADP-Receptor Inhibitors in the Perioperative Period: The Good, the Bad, and the Ugly

THE MANAGEMENT OF P2Y12-receptor inhibitors in the perioperative period represents a very common, yet controversial, area of the daily practice of most anesthesiologists. Dual antiplatelet therapy (DAPT), consisting of a P2Y12-receptor inhibitor in addition to aspirin, represents the standard of care for patients with coronary stents. Premature discontinuation of DAPT may lead to stent thrombosis (ST) with subsequent acute coronary events. Therefore, clinicians need to carefully balance the procedural bleeding risk while continuing therapy versus the thrombotic risk associated with stopping DAPT.

Drug-eluting Stents: Will the transformation to bioabsorption make durable polymers obsolete?

It's been over a decade since drug-eluting stents (DES) were introduced into the clinical practice of percutaneous coronary intervention for the treatment of coronary artery lesions. With significant reductions in restenosis rates and the need for repeat revascularizations, the technology was disseminated globally at an unprecedented rate [1]. Soon after, reports of early and late stent thrombosis curbed the enthusiasm and mandated selective DES uses and prolonged dual antiplatelet therapy (DAPT) for at least 12months [2]. This strategy significantly reduced stent thrombosis rates, albeit at the price of bleeding, which has often led to premature DAPT discontinuation [3]. Additionally, first-generation DES, Cypher and Taxus, reported a stent thrombosis increasing hazard of 0.6 per year up to 5 years and even higher rates of target lesion failure [4]. Firstgeneration DES were then replaced with second-generation DES that utilize a thinner cobalt chromium or platinum chromium alloy, sirolimus analogue drugs, such as everolimus and zotarolimus, and a thinner and more biocompatible polymer layer. Despite these iterations, the requirement for prolonged DAPT did not change. At the same time, the hazard ratios for stent thrombosis and target vessel failure were attenuated, but not eliminated, especially in the more complex patient and lesion subsets [5,6]. The question remains, “What factors contribute to the development of the late events seen in second-generation DES?” Is it the metal? The polymer? Or is it the drug? For BMS, target vessel failure occurs within the first 6–12 months, and events beyond that are rare. With second-generation DES, the drug is gone within the first 6 months and complete healing is usually attained at 12 months. This suggests that the culprit for these late events (N12 months) is most likely the polymer, which continues to irritate the vessel wall causing low grade inflammation and subsequently neoatherosclerosis. The polymers used in first-generation DES were associated with a high degree of inflammation, which often resulted in vessel wall toxicity, target lesion failure, and late stent thrombosis. Nevertheless, the polymers used in the second-generation DES, such as BioLinx and fluoropolymer, are proven to be more biocompatible. More specifically, the fluoropolymer used in Xience V (Abbott Vascular) and Promus Element stents (Boston Scientific) have further claimed to have antithrombotic properties and protection from stent thrombosis when compared to BMS [7]. However, the data to support this claim are rather weak and did not result in a change in the recommended duration of DAPT for such stents. Further, in the Prospective, Randomized, Multicenter Trial to Assess

Management of Perioperative Antiplatelet Therapy

Drug-eluting stent (DES) implatation was the major method of coronary revascularization and marked reduction in target-lesion revascularization. Stent thrombosis (ST) is a severe complication that is associated with a high incidence of acute myocardial infarction and death. To prevent ST, dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended for at least 12 months. The premature discontinuation of DAPT is the single most significant predictor of perioperative ST. The risk of surgical bleeding is increased approximately 20% by aspirin or clopidogrel alone, and 50% by DAPT. But the increased risk of perioperative bleeding is not necessarily associated with increased mortality or surgical outcome. Usually, the risk of a cardiovascular event when stopping antiplatelet agents preoperatively is higher than the risk of surgical bleeding when continuing these drugs, except during high risk surgery in a closed space. We remember that DES are never low risk situation for ST and aspirin must never be stopped in all patients with DES. (Korean J Med 2013;85:22-28)