Short-term Dual Antiplatelet Therapy Research Articles

Stroke Prevention With Left Atrial Appendage Closure in Patients With Atrial Fibrillation and Prior Intracranial Hemorrhage

BackgroundOral anticoagulation (OAC) is deemed a relative contraindication after intracranial hemorrhage (ICH) if the cause cannot be eliminated and the risk of recurrence is high. That leaves atrial fibrillation (AF) patients at high risk of thromboembolic events. Endovascular left atrial appendage closure (LAAC) can be an alternative to OAC for patients requiring stroke prevention. MethodsWe performed a retrospective single-centre analysis of 138 consecutive ICH patients with nonvalvular AF and high stroke risk who underwent LAAC between 2010 and 2022 at Vancouver General Hospital. We report the baseline characteristics, procedural results, and follow-up data, comparing the observed stroke/transient ischemic attack (TIA) rate with the predicted event rate based on their CHA2DS2-VASc scores. ResultsThe average age was 76.1 ± 8.5 years; the mean CHA2DS2-VASc score was 4.4 ± 1.5; and the mean HAS-BLED score was 3.7 ± 0.9. The procedural success rate was 98.6%, and the complication rate was 3.6% with no periprocedural death, stroke, or TIA. The antithrombotic regimen post-LAAC consisted of short-term dual antiplatelet therapy (1-6 months) followed by aspirin alone for a minimum of 6 months in 86.2%. At mean follow-up of 14.7 ± 13.7 months, 9 deaths (6.5%, 7 cardiovascular, 2 noncardiovascular), 2 strokes (1.4%), and 1 TIA (0.7%) had occurred. The annualized observed stroke/TIA rate was 1.8%, which was lower than the adjusted predicted stroke rate of 7.0% (95% confidence interval: 4.8%-9.2%). Two patients (1.5%) suffered another ICH (both on aspirin monotherapy). One device-related thrombus (0.7%) was confirmed and treated with OAC without sequelae. ConclusionEndovascular LAAC is a feasible alternative to OAC for stroke prevention in patients with nonvalvular AF and prior ICH.

Graft thrombosis after coronary artery bypass surgery and current practice for prevention.

Coronary artery bypass grafting (CABG) is the most frequently performed cardiac surgery worldwide. The reported incidence of graft failure ranges between 10% and 50%, depending upon the type of conduit used. Thrombosis is the predominant mechanism of early graft failure, occurring in both arterial and vein grafts. Significant advances have been made in the field of antithrombotic therapy since the introduction of aspirin, which is regarded as the cornerstone of antithrombotic therapy for prevention of graft thrombosis. Convincing evidence now exists that dual antiplatelet therapy (DAPT), consisting of aspirin and a potent oral P2Y12 inhibitor, effectively reduces the incidence of graft failure. However, this is achieved at the expense of an increase in clinically important bleeding, underscoring the importance of balancing thrombotic risk and bleeding risk when considering antithrombotic therapy after CABG. In contrast, anticoagulant therapy has proved ineffective at reducing the occurrence of graft thrombosis, pointing to platelet aggregation as the key driver of graft thrombosis. We provide a comprehensive review of current practice for prevention of graft thrombosis and discuss potential future concepts for antithrombotic therapy including P2Y12 inhibitor monotherapy and short-term DAPT.

Comparison Of 3-6 Month Versus 12 Month Dual Antiplatelet Therapy After Coronary Intervention Using the Contemporary Drug-eluting Stents With Ultrathin Struts: The HOST-IDEA Randomized Clinical Trial.

Background: Limited data are available on short-term dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) using third-generation drug-eluting stents (DES) with ultrathin struts and advanced polymer technology. We investigated whether 3-6 month DAPT was non-inferior to 12 month one after implantation of DES with ultrathin struts and advanced polymer technology. Methods: We performed an open-label, randomized trial at 37 centers in South Korea. We enrolled patients undergoing PCI using the Orsiro biodegradable-polymer sirolimus-eluting stents (SES) or the Coroflex ISAR polymer-free SES. Patients with ST-segment elevation myocardial infarction were excluded. Patients were randomized to receive either 3-6 month or 12 month DAPT after PCI. The choice of antiplatelet medications was at the physician's discretion. The primary outcome was a net adverse clinical event (NACE), a composite of cardiac death, target vessel myocardial infarction (TVMI), clinically driven target lesion revascularization (CD-TLR), stent thrombosis, or major bleeding, defined as Bleeding Academic Research Consortium type 3 or 5 at 12 months. The major secondary outcomes were target lesion failure (TLF), a composite of cardiac death, TVMI, CD-TLR, and major bleeding. Results: A total of 2,013 patients (mean age 65.7±10.5, 1,487 male [73.9%], 1,110 [55.1%] presented with acute coronary syndrome) were randomized to 3-6 month DAPT (n=1,002) or 12 month DAPT (n=1,011). The primary outcome occurred in 37 (3.7%) patients in the 3-6 month DAPT group and 41 (4.1%) in the 12 month DAPT group. The non-inferiority of the 3-6 month DAPT group to the 12 month DAPT group was met (absolute risk difference, -0.4% [1-sided 95% confidence interval (CI), -∞% to 1.1%; P<0.001 for non-inferiority]). There were no significant differences in TLF (hazard ratio [HR] 0.98, 95% CI 0.56-1.71, P=0.94) or major bleeding (HR 0.82, 95% CI 0.41-1.61, P=0.56) between the two groups. Across various subgroups, the treatment effect of 3-6 month DAPT was consistent for NACE. Conclusions: Among patients undergoing PCI using third-generation DES, 3-6 month DAPT was non-inferior to 12 month DAPT for NACE. Further research is needed to generalize this finding to other populations and to determine the ideal regimen for 3-6 month DAPT.

Acute Ischemic Stroke Management: A Systematic Review

With the increasing improvement of living standards, stroke also has a very high incidence rate in the world, in which ischemic stroke accounts for 60%-80% [1]. But many people, even medical students, know very little about stroke treatment. Therefore, I intend to write a review of the treatment of Acute Ischemic Stroke (AIS), which will give the reading public a systematic understanding of the treatment of acute ischemic stroke, reduce the public’s fear of stroke, and make patients and their families trust doctors. This article focuses on the treatment options for mild ischemic stroke and heavy ischemic stroke. The treatment options for mild ischemic stroke are thrombolytic therapy or short-term dual antiplatelet therapy [2]; the treatment options for heavy ischemic stroke are bridging therapy or direct endovascular intervention.

Safety and efficacy of short-term dual antiplatelet therapy combined with intensive rosuvastatin in acute ischemic stroke

To investigate the safety and efficacy of short-term (7-day) Dual Antiplatelet Therapy (DAPT) with intensive rosuvastatin in Acute Ischemic Stroke (AIS). In this study, patients with AIS in the emergency department of the hospital from October2016 to December2019 were registered and divided into the control group (Single Antiplatelet Therapy [SAPT]+ rosuvastatin) and the study group (7-day DAPT+intensive rosuvastatin) according to the therapy regimens. The generalized linear model was used to compare the National Institute of Health Stroke Scale (NIHSS) scores between the two groups during the21-day treatment. A Cox regression model was used to compare recurrent ischemic stroke, bleeding events, Statin-Induced Liver Injury (SILI), and Statin-Associated Myopathy (SAM) between the two groups during the90-day follow-up. Comparison of NIHSS scores after21-day treatment: NIHSS scores in the study group decreased significantly, 0.273-times as much as that in the control group (Odds Ratio [OR]0.273; 95%Confidence Interval [95%CI]0.208-0.359; p < 0.001). Comparison of recurrent ischemic stroke during the90-day follow-up: The therapy of the study group reduced the risk of recurrent stroke by 65% (7.76%vs.22.82%, Hazard Ratio [HR]0.350; 95%CI0.167-0.730; p=0.005). Comparison of bleeding events: There was no statistical difference between the two groups (7.79%vs.6.71%, HR=1.076; 95%CI0.424-2.732; p=0.878). No cases of SILI and SAM were found. Short-term DAPT with intensive rosuvastatin effectively relieved the clinical symptoms and significantly reduced the recurrent stroke for patients with mild-to-moderate AIS within90 days, without increasing bleeding events, SILI and SAM.

P2y12 inhibitor monotherapy after 1-3 months dual antiplatelet therapy in patients with coronary artery disease and chronic kidney disease undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials.

In patients with coronary artery disease (CAD) and chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI), whether short-term dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitors confers benefits compared with standard DAPT remains unclear. This study aimed to assess the efficacy and safety of 1-3 months of DAPT followed by P2Y12 monotherapy in patients with CAD and CKD undergoing PCI. PubMed, Embase, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) comparing the P2Y12 inhibitor monotherapy after a 1-3 months DAPT vs. DAPT in patients with CAD and CKD after PCI. The primary outcome was the incidence of major adverse cardiovascular events (MACEs), defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, target-vessel revascularization, and stroke. The safety outcome was the major bleeding events, defined as a composite of TIMI major bleeding or Bleeding Academic Research and Consortium (BARC) type 2, 3, or 5 bleeding. The pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated with a fixed- or random-effects model depending on the heterogeneity among studies. Four RCTs including 20,468 patients (2,833 patients with CKD and 17,635 without CKD) comparing P2Y12 inhibitor monotherapy with DAPT were included in our meta-analysis. Patients with CAD and CKD had higher risk of ischemic and bleeding events. P2Y12 inhibitor monotherapy after 1-3 months of DAPT significantly reduced the risk of major bleeding compared to DAPT in CKD patients (RR: 0.69, 95% CI: 0.51-0.95, P = 0.02) and non-CKD patients (RR: 0.66, 95% CI: 0.49-0.89, P = 0.01). No significant difference regarding MACEs between P2Y12 inhibitor monotherapy and DAPT was found in CKD patients (RR: 0.88, 95% CI: 0.59-1.31, P = 0.53) and non-CKD (RR: 0.91, 95% CI: 0.79-1.04, P = 0.17). P2Y12 inhibitor monotherapy after 1-3 months of DAPT was an effective strategy for lowering major bleeding complications without increasing the risk of cardiovascular events in patients with CAD and CKD undergoing PCI as compared with DAPT. https://www.crd.york.ac.uk/PROSPERO/, CRD42022355228.

Short-term dual antiplatelet therapy for 1-3 months after percutaneous coronary intervention using drug eluting stents: A systematic review and meta-analysis of randomized clinical trials.

The optimal dual antiplatelet therapy (DAPT) duration and regimen in patients undergoing percutaneous coronary intervention (PCI) using current generation drug eluting stents (DES) is still unclear. To compare the safety and efficacy of short-term DAPT (S-DAPT) with longer duration DAPT (l-DAPT) after contemporary PCI. We searched for studies comparing S-DAPT (≤3 months) followed by single antiplatelet therapy (SAPT) with aspirin or a P2Y12 inhibitor against L-DAPT (6-12 months) after PCI with current generation DES. Primary end-points of interest were major bleeding and stent thrombosis (ST) at 1 year. Random-effects meta-analyses were performed to calculate odds ratios with 95% CIs. Eleven RCTs (n = 48,946) were included in the primary analysis. Major bleeding was significantly lower with S-DAPT (n = 24,424) (odd ratio [OR0.65; 95% confidence interval,CI0.52-0.80]) compared with L-DAPT (n = 24,486). There were no differences in ST between the two groups [OR 1.26; 95% CI 0.97-1.63]. There were no significant differences in risks of all-cause death, cardiovascular death or myocardial infarction between S-DAPT and L-DAPT groups. In a subgroup analysis, there was borderline significantly higher ST with 1 month S-DAPT [1.39; 1.0-1.92], but not with 3 months S-DAPT [1.07; 0.70-1.64], when compared to L-DAPT. Finally, there were no significant treatment interactions observed when trials using SAPT with aspirin were compared with those using P2Y12 inhibitor monotherapy. Among patients undergoing current generation DES implantation, S-DAPT for 1-3 months reduces major bleeding without an increase in ischemic events compared with L-DAPT. Three months S-DAPT might provide a better risk-benefit profile based on current analysis. Further study is needed to define the SAPT of choice after 1-3 months DAPT.

Abstract 12107: Short-Term and De-Escalation Dual Antiplatelet Therapy for Patients With Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis

Background: Short-term (&lt;6 month) or de-escalation (e.g. switching potent P2Y 12 inhibitors to less potent/lower-dose agents a month after the event) dual antiplatelet therapy (DAPT) have become an attractive therapeutic strategy for patients with acute coronary syndrome (ACS). However, these strategies have never been randomly compared. Methods: PubMed, EMBASE, and Cochrane Central were searched in April 2022. Randomized controlled trials (RCTs) or their subgroup analyses that included ACS patients, with standard (12 months), extended (≥18 months), short-term and unguided de-escalation DAPT strategy, along with the guided DAPT strategy with genotype or platelet function tests were identified. The efficacy outcome (major adverse cardiovascular events: MACE) was defined as a composite of cardiovascular death, myocardial infarction, or stroke. The safety outcomes were mainly defined as major or minor bleeding, and major bleeding. Results: This network meta-analysis included 32 RCTs with 103,497 patients. While there was no significant difference in efficacy among the short DAPT, unguided de-escalation and guided-selection strategy, the unguided de-escalation strategy alone was associated with reduced risks of MACE compared with standard DAPT (e.g. versus DAPT with clopidogrel; HR [95% CI]: 0.66 [0.48-0.91]). Both the short DAPT and de-escalation strategies were associated with reduced risks of major or minor bleeding compared with other strategies including the guided-selection (HR [95% CI]: 0.66 [0.47-0.93], 0.48 [0.33-0.71], respectively); the short DAPT strategy alone was associated with a reduced risk of major bleeding compared with standard, extended and guided-selection DAPT (HR [95%CI]: 0.55 [0.33-0.92]). Conclusions: In ACS patients, the unguided de-escalation strategy was associated with reduced risks of MACE, while the short DAPT strategy was associated with decreased rates of major bleeding compared with standard DAPT, suggesting both strategies can be used in select patients by balancing patients’ ischemic and bleeding risks.

25 EVALUATION OF PATIENTS PRESENTING WITH TIA IN THE AMAU AND TIA FAST ASSESSMENT CLINICS - ARE WE MEETING ESO GUIDELINES?

Abstract Background The European Stroke Organisation published guidelines on the management of Transient Ischaemic Attack (TIA) in 2021. Specialist review of suspected TIA is recommended within 24-hours of symptom onset in a TIA clinic. They suggest using CT or MR angiogram for additional confirmation of large artery stenosis of &amp;gt;50%. They advise against the use of prediction tools alone e.g. ABCD2 score when identifying high-risk patients. Dual antiplatelet therapy is recommended short-term in high risk, non cardio-embolic TIA patients. This audit evaluates if these guidelines are being followed in our institution. Methods We evaluated all patients attending the TIA clinic and the Acute Medical Assessment Unit (AMAU) with suspected TIA over a three-week period in 2021 in a single tertiary referral centre. Retrospective data was collected based on chart review. Results Twenty patients underwent review in the TIA clinic and eight in the AMAU with suspected TIA in the chosen time period. One patient (3.5%) was seen within 24 hours from symptom onset, 2 were seen within 24-36 hours (7.1%), 4 patients (14.2%) were seen within 36-72 hours, 21 patients (75%) were seen &amp;gt;72 hours after symptom onset. In all patients who had a doppler US showing &amp;gt;50% carotid stenosis, a CT angiogram was performed. ABCD2 scores were recorded but used in combination with clinical judgment. All patients with high-risk, non-cardioembolic TIA received early, short-term dual antiplatelet therapy. Conclusion The diagnostic methods and treatment strategies in place for patients attending the TIA clinic or AMAU with TIA were in keeping with the recently published ESO guidelines. However, there was a time delay from symptom onset to time of review in many patients. Further studies are indicated to identify the potential mechanisms behind these delays. Interventions to ensure that we are meeting this ‘time-to-review’ target in patients could be implemented, ensuring high quality, evidence-based care.

Efficacy and safety of dual antiplatelet therapy after percutaneous coronary drug-eluting stenting: A network meta-analysis.

Background:To evaluate the efficacy and safety of dual antiplatelet regimens after coronary drug-eluting stenting by network meta-analysis (NMA).Methods:PubMed, The Cochrane Library, Embase, and Web of Science databases were electronically searched to collect randomized controlled trials (RCTs) of the comparison of different dual antiplatelet regimens after coronary drug-eluting stenting from inception to September 1st, 2021. Two reviewers independently screened literature, extracted data, and assessed the risk bias of included studies. Stata 16.0 software was used for NMA.Results:A total of 27 RCTs involving 79,880 patients were included. The results of NMA: in terms of myocardial infarction (MI), other 3 interventions were higher than the long-term dual antiplatelet therapy (L-DAPT) (the standard dual antiplatelet therapy [Std-DAPT] [odds ratio [OR] = 1.82, 95%confidence interval [CI]: 1.49-2.21), the aspirin monotherapy after short-term dual antiplatelet therapy (S-DAPT + As) (OR = 2.06, 95%CI: 1.57-2.70), the P2Y12 inhibitor monotherapy after short-term dual antiplatelet therapy (S-DAPT + P2Y12) (OR = 1.71, 95%CI: 1.29-2.28)]. In terms of stent thrombosis, other 3 interventions were higher than L-DAPT [Std-DAPT (OR = 2.18, 95%CI: 1.45-3.28), S-DAPT + As (OR = 2.32, 95%CI: 1.52-3.54), S-DAPT + P2Y12 (OR = 2.31, 95%CI: 1.22-4.36)]. There was no statistically significant difference among the 4 interventions in prevention of stroke and all-cause mortality (P > .05). In terms of cardiovascular and cerebrovascular adverse events, other 3 interventions were higher than L-DAPT (Std-DAPT [OR = 1.28, 95%CI: 1.12-1.45], S-DAPT + As [OR = 1.27, 95%CI: 1.09-1.48], S-DAPT + P2Y12 [OR = 1.24, 95%CI: 1.01-1.52]). In terms of safety, bleeding rate of other 3 interventions were lower than L-DAPT (Std-DAPT [OR = 0.67, 95%CI: 0.52-0.85], S-DAPT + As [OR = 0.51, 95%CI: 0.39-0.66], S-DAPT + P2Y12 [OR = 0.36, 95%CI: 0.26-0.49]). Two interventions were lower than L-DAPT (S-DAPT + As [OR = 0.77, 95%CI: 0.65-0.90], S-DAPT + P2Y12 [OR = 0.54, 95%CI: 0.44-0.66]). S-DAPT + As was higher than L-DAPT (OR = 1.42, 95%CI: 1.10-1.83).Conclusions:S-DAPT + P2Y12 has the lowest bleeding risk, while L-DAPT has the highest bleeding risk. In the outcome of MI, stent thrombosis, and cardiovascular and cerebrovascular adverse events, L-DAPT has the best efficacy. In the outcome of stroke and all-cause mortality, the 4 interventions were equally effective.

Navigating Antiplatelet Treatment Options for Stroke: Evidence-Based and Pragmatic Strategies.

The benefit of using antiplatelet monotherapy in acute ischemic stroke and secondary stroke prevention is well established. In the last few years, several large randomized trials showed that the use of short-term dual antiplatelet therapy in particular stroke subtypes may reduce the risk of recurrent ischemic events. The aim of this article is to provide a critical analysis of the current evidence and recommendations for the use of antiplatelet agents for stroke prevention. Long-term therapy with aspirin, clopidogrel, or aspirin plus extended-release dipyridamole is recommended for secondary stroke prevention in patients with noncardioembolic ischemic stroke. Short-term dual antiplatelet therapy with aspirin and clopidogrel is superior to antiplatelet monotherapy in secondary stroke prevention when used in patients with mild noncardioembolic stroke or high-risk transient ischemic attack. Dual therapy, however, is associated with an increased risk of major bleeding, particularly when the treatment is extended for greater than 30days. Similarly, aspirin plus ticagrelor is superior to aspirin monotherapy for the prevention of recurrent ischemic stroke, although this combination is associated with a higher risk of hemorrhagic complications when compared to other dual antiplatelet regimens. Among patients who carry CYP2C19 genetic polymorphisms associated with a slow bioactivation of clopidogrel, short-term treatment with aspirin plus ticagrelor is superior to aspirin plus clopidogrel for the reduction of recurrent stroke; however, the use of ticagrelor is associated with a higher risk of any bleeding. In patients with symptomatic intracranial stenosis, aggressive medical management in addition to dual antiplatelet therapy up to 90days is recommended. Antiplatelet therapy has an essential role in the management of ischemic stroke. The specific antiplatelet regimen should be individualized based on the stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications.

Short-term DAPT after coronary stenting has similar ischemic and bleeding outcomes as long-term DAPT: a 5-year population-based cohort study.

Optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) remains controversial. We investigated the relationship between DAPT duration following PCI and long-term ischemic and bleeding outcomes under real-world conditions. Patients aged ≥ 65years who underwent PCI with stenting in Western Australian hospitals between 2003 and 2008 and survived 2years were identified from linked hospital admissions data. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE) defined as a composite of all-cause death and admissions for acute coronary syndrome (ACS), coronary artery revascularization procedure, stroke, and major bleeding. Secondary outcomes were ACS admissions, all-cause death, and major bleeding admissions. Patients were followed up for 5years from initial PCI. A total of 3963 patients were included in the final analysis. The mean age of the cohort was 74.5 ± 6.1years with 67.3% males. No significant difference was seen with 6-12, 12-18, or 18-24months DAPT, compared to 0-6months DAPT duration for MACCE and all secondary outcomes at 3- and 5-year post-PCI. There is no significant difference in both bleeding and ischemic outcomes in long-term DAPT as compared to short-term DAPT for first- and second-generation drug-eluting stents in a real-world population.

Comparison of Short-Term DAPT and Long-Term DAPT on the Prognosis of PCI Patients: A Meta-Analysis of Randomized Controlled Trials.

Dual antiplatelet therapy (DAPT) is the primary medication for patients after percutaneous coronary intervention (PCI). However, the best DAPT duration is still controversial. This systematic review and meta-analysis aims to assess the safety and effectiveness of short-term (3-6 months) DAPT compared to long-term (12 months) DAPT. We searched PubMed, Embase, Cochrane Library, and Web of Science systematically for all the randomized controlled trials (RCTs) which compared the different strategies for DAPT in patients undergoing PCI within ten years prior to January 2021. Major bleeding and any bleeding were identified as the safe endpoints. All causes of death, cardiac death, myocardial infarction, definite/probable stent thrombosis, target vessel revascularization, and stroke were identified as the efficacy endpoints. The hazard ratio (HR) and 95% confidence interval (CI) in each study were abstracted. Overall, 11 trials and 24,242 patients were included in this meta-analysis with 15-month median follow-up time. Short-term DAPT was related to reduced risks of major bleeding (HR 0.65, 95% CI 0.48-0.89) and any bleeding (HR 0.64, 95% CI 0.53-0.79). No obvious differences in any of the other endpoints were observed. In acute coronary syndrome (ACS) patients with drug-eluting stents (DES), short-term compared with long-term DAPT was related to a decreased risk of major bleeding (HR 0.57, 95% CI 0.37-0.87) without significant increasing in the risks of any bleeding and ischemic endpoints. Furthermore, short-term DAPT followed by P2Y12 receptor inhibitor monotherapy appreciably lowered the risk of major bleeding (HR 0.64, 95% CI 0.42-0.96) and any bleeding (HR 0.58, 95% CI 0.36-0.93). There were no obvious differences concerning death between the different strategies for DAPT. After PCI with DES, short-term DAPT is safer than long-term DAPT, and is not inferior in effectiveness, even in ACS patients. P2Y12 receptor inhibitor monotherapy following short-term DAPT is also related to a decreased risk of bleeding and may be an alternative anti-platelet strategy.

Techniques and Evidence for Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: An Ongoing Journey

Techniques and Evidence for Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: An Ongoing Journey

TCT-21 Preferred Strategy in the Era of Short-Term Dual Antiplatelet Therapy: A Systematic Review and Network Meta-analysis of Randomized Trials

TCT-21 Preferred Strategy in the Era of Short-Term Dual Antiplatelet Therapy: A Systematic Review and Network Meta-analysis of Randomized Trials

Early P2Y12 Inhibitor Single Antiplatelet Therapy for High-Bleeding Risk Patients After Stenting - PENDULUM Mono 24-Month Analysis.

In PENDULUM mono, Japanese patients with high bleeding risk (HBR) received short-term dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy (SAPT) with prasugrel after percutaneous coronary intervention (PCI). One-year data from PENDULUM mono showed better outcomes with prasugrel monotherapy after short-term DAPT compared with matched patients in the PENDULUM registry with longer DAPT durations according to guidelines at that time. This study presents 2-year results.Methods and Results: We compared 24-month data from PENDULUM mono (n=1,107; de-escalation strategy group) and the PENDULUM registry (n=2,273; conventional strategy group); both were multicenter, non-interventional, prospective registry studies, using the inverse probability of treatment weighting (IPTW) method. In the PENDULUM mono group, the cumulative incidence of clinically relevant bleeding (CRB) at 24 months post-PCI (primary endpoint) was 6.8%, and that of major adverse cardiac and cerebrovascular events (MACCE) was 8.9%. After IPTW adjustment, the cumulative incidence of CRB was 5.8% and 7.2% in PENDULUM mono and the PENDULUM registry, respectively (hazard ratio [HR] 0.77; 95% confidence interval [CI] 0.57-1.04; P=0.086), and that of MACCE was 8.0% and 9.5%, respectively (HR 0.77; 95% CI 0.59-1.01; P=0.061). Japanese PCI patients with HBR prescribed prasugrel SAPT after short-term DAPT had a lower ischemic event risk than those prescribed long-term DAPT, and this was particularly relevant for ischemic events after 1 year.

Efficacy and Safety of Shortened Dual Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials.

To update the efficacy and safety of short-term (≤3 months) dual antiplatelet therapy (DAPT) and standard (6-12 months) DAPT in patients undergoing percutaneous coronary intervention. In addition, we also explored the duration of DAPT in patients at high bleeding risk (HBR). In PubMed, Embase, and Cochrane Library, we electronically searched among all the studies from the establishment of the database to December 8, 2021, for randomized controlled trials (RCTs). Nine randomized controlled trials (45,661 patients) ultimately met the inclusion criteria. The pooled analysis revealed that, compared with standard DAPT, ≤3-month DAPT significantly reduced major adverse cardiovascular event {hazard ratio (HR) = 0.89, 95% confidence interval (CI) [0.82-0.97]}, all-cause mortality [HR = 0.88, 95% CI (0.78-0.99)], cardiovascular mortality [HR = 0.79, 95% CI (0.65-0.97)], major bleeding [HR = 0.72, 95% CI (0.56-0.93)], and any bleeding [HR = 0.57, 95% CI (0.50-0.66)], while no significant differences in the risk of myocardial infarction, stent thrombosis, and stroke. In patients with HBR, the results showed that ≤3-month DAPT significantly reduced major bleeding [HR = 0.35, 95% CI (0.14-0.88)] and any bleeding [HR = 0.53, 95% CI (0.41-0.67)] compared with standard DAPT, while the risk of other outcomes was not statistically different. In conclusion, this study showed that ≤3-month DAPT may be a valid option for most patients after percutaneous coronary intervention. Because reductions in major adverse cardiovascular event, all-cause mortality, and cardiovascular mortality were not seen in patients with HBR, this also highlights the need for specific studies in these patients about optimal duration of antiplatelet therapy.

Dual Antiplatelet Therapy for 3 or 12 Months in Patients with Non-ST-elevation MI/Unstable Angina or ST-elevation MI: Analysis of the REDUCE Trial

Background: The aim of this subanalysis of the REDUCE (Short-term Dual Antiplatelet Therapy in Patients with ACS Treated with the COMBO Dual-therapy Stent) trial was to evaluate differences between non-ST-elevation MI/unstable angina (NSTEMI/UA) patients and ST-elevation MI (STEMI) patients in terms of patient characteristics, procedures and outcomes. Methods: In the REDUCE trial, 1,496 acute coronary syndrome patients undergoing successful COMBO stent implantation were randomised to 3 or 12 months of dual antiplatelet therapy (DAPT) treatment. In total, 789 (52.8%) patients had NSTEMI/UA and 706 (47.2%) had STEMI. For this analysis, NSTEMI/UA patients (n=789) were compared with STEMI patients (n=706). Results: In the analysis of the NSTEMI/UA and STEMI cohorts comparing 3-month DAPT (751 patients) and 12-month DAPT treatment (745 patients) there were no statistically significant differences in the primary endpoints of all-cause mortality, MI, stent thrombosis, stroke, target vessel revascularisation or bleeding (Bleeding Academic Research Consortium [BARC] II, III, V) at 360 and 720 days between the two cohorts. Comparing the overall primary endpoints in the NSTEMI/UA cohort, 3-month DAPT was better than 12-month DAPT (9.6% versus 10.0% at 360 days and 12.1% versus 15.0% at 720 days). In the STEMI cohort, 12-month DAPT was better than 3-month DAPT (8.4% versus 11.0% at 720 days). Conclusion: For NSTEMI/UA patients, a numerically lower occurrence of outcomes was observed with 3-month DAPT at 360 and 720 days, whereas for STEMI patients, 12-month DAPT appeared to be better at 720 days. NSTEMI patients seemed to have less favourable long-term outcomes than STEMI patients in this subanalysis. Further adequately powered randomised trials are needed to confirm the findings.

Treatment of posterior circulation stroke: Acute management and secondary prevention.

One-fifth of strokes occur in the territory of the posterior circulation, but their management, particularly acute reperfusion therapy and neurointervention procedures for secondary prevention, has received much less attention than similar interventions for the anterior circulation. In this review, we overview the treatment of posterior circulation stroke, including both interventions in the acute setting and secondary prevention. We focus on areas in which the management of posterior circulation stroke differs from that of stroke in general and highlight recent advances.Effectiveness of acute revascularization of posterior circulation strokes remains in large parts unproven. Thrombolysis seems to have similar benefits and lower hemorrhage risks than in the anterior circulation. The recent ATTENTION and BAOCHE trials have demonstrated that thrombectomy benefits strokes with basilar artery occlusion, but its effect on other posterior occlusion sites remains uncertain. Ischemic and hemorrhagic space-occupying cerebellar strokes can benefit from decompressive craniectomy.Secondary prevention of posterior circulation strokes includes aggressive treatment of cerebrovascular risk factors with both drugs and lifestyle interventions and short-term dual anti-platelet therapy. Randomized controlled trial (RCT) data suggest basilar artery stenosis is better treated with medical therapy than stenting, which has a high peri-procedural risk. Limited data from RCTs in stenting for vertebral stenosis suggest that intracranial stenosis is currently best treated with medical therapy alone; the situation for extracranial stenosis is less clear where stenting for symptomatic stenosis is an option, particularly for recurrent symptoms; larger RCTs are required in this area.

Optimal Duration of Dual Antiplatelet Therapy after Stent- Assisted Coil Embolization of Unruptured Intracranial Aneurysms : A Prospective Randomized Multicenter Trial.

Stent-assisted coil embolization (SAC) has been increasingly used to treat various types of intracranial aneurysms. Delayed thromboembolic complications are major concerns regarding this procedure, so dual antiplatelet therapy with aspirin and clopidogrel is needed. However, clinicians vary the duration of dual antiplatelet therapy after SAC, and no randomized study has been performed. This study aims to compare the safety and efficacy of long-term (12 months) dual antiplatelet therapy and shortterm dual antiplatelet therapy (6 months) after SAC for patients with unruptured intracranial aneurysms (UIAs). This is a prospective, randomized and multicenter trial to investigate the optimal duration of dual antiplatelet therapy after SAC in patients with UIAs. Subjects will receive dual antiplatelet therapy for 6 months (short-term group) or 12 months (longterm group) after SAC. The primary endpoint is the assessment of thromboembolic complications between 1 and 18 months after SAC. We will enroll 528 subjects (264 subjects in each group) and perform 1 : 1 randomization. This study will involve 14 topperforming, high-volume Korean institutions specializing in coil embolization. The trial will begin enrollment in 2022, and clinical data will be available after enrollment and follow-up. This article describes that the aim of this prospective randomized multicenter trial is to compare the effect of short-term (6 months) and long-term (12 months) dual antiplatelet therapy on UIAs in patients undergoing SAC, and to find the optimal duration.