Dual Antiplatelet Therapy After Complex PCI

Study Questions:

What is the efficacy and safety of long-term (≥12 months) versus short-term (3 or 6 months) dual antiplatelet therapy (DAPT) with aspirin and clopidogrel according to percutaneous coronary intervention (PCI) complexity?


The investigators pooled patient-level data from six randomized controlled trials investigating DAPT durations after PCI. Complex PCI was defined as having at least one of the following features: three vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with two stents implanted, total stent length >60 mm, or chronic total occlusion. The primary efficacy endpoint was major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction (MI), or stent thrombosis. The primary safety endpoint was major bleeding. Intention-to-treat was the primary analytic approach.


Of 9,577 patients included in the pooled data set for whom procedural variables were available, 1,680 (17.5%) underwent complex PCI. Overall, 85% of patients received new-generation drug-eluting stents. At a median follow-up time of 392 days (interquartile range, 366-710 days), patients who underwent complex PCI had a higher risk of MACE (adjusted hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.50-2.60; p < 0.0001). Compared with short-term DAPT, long-term DAPT yielded significant reductions in MACE in the complex PCI group (adjusted HR, 0.56; 95% CI, 0.35-0.89) versus the noncomplex PCI group (adjusted HR, 1.01; 95% CI, 0.75-1.35; pinteraction = 0.01). The magnitude of the benefit with long-term DAPT was progressively greater per increase in procedural complexity. Long-term DAPT was associated with increased risk for major bleeding, which was similar between groups (pinteraction = 0.96). Results were consistent by per-treatment landmark analysis.


The authors concluded that procedural complexity is an important parameter to take into account in tailoring upfront duration of DAPT.


This non–prespecified, post hoc analysis reports that in patients who underwent complex PCI, compared with a short period of DAPT (3 or 6 months), long-term DAPT (≥1 year) significantly reduced the risk of cardiac ischemic events with a magnitude that was greater for higher procedural complexity. The results suggest that, along with other well-established clinical ischemic risk factors, complexity of coronary artery stenting is an important parameter to take into account in tailoring upfront duration of DAPT, and possibly potency, for cardiac ischemic protection. However, long-term DAPT was also associated with an increased risk of major bleeding, irrespective of procedural complexity. Prospective randomized trials are indicated to assess the ischemic benefits versus bleeding risk of longer-term DAPT for complex PCI.

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