Impact of Stent Design and Length of DAPT

Study Questions:

What is the differential impact on ischemic and bleeding events of the type of drug-eluting stent (durable polymer stents [DES] vs. biodegradable polymer stents vs. bioresorbable scaffolds [BRS]) and length of dual antiplatelet therapy (DAPT)?

Methods:

Randomized controlled trials comparing different types of DES and/or DAPT durations were selected. The primary endpoint was major adverse cardiovascular events (MACE) (a composite of death, myocardial infarction [MI], and target vessel revascularization). Definite stent thrombosis (ST) and single components of MACE were secondary endpoints. The arms of interest were: BRS with 12 months of DAPT (12mDAPT), biodegradable polymer stent with 12mDAPT, durable polymer stent (everolimus-eluting [EES], zotarolimus-eluting [ZES] with 12mDAPT), EES/ZES with <12 months of DAPT, and EES/ZES with >12 months of DAPT (DAPT >12 m).

Results:

Sixty-four studies with 150 arms and 102,735 patients were included. After a median follow-up of 20 months, MACE rates were similar in the different arms of interest. EES/ZES with DAPT >12 m reported a lower incidence of MI than the other groups, while BRS showed a higher rate of ST when compared to EES/ZES, irrespective of DAPT length. A higher risk of major bleedings was observed for DAPT >12 m as compared to shorter DAPT.

Conclusions:

The authors concluded that stent type may partially affect the outcome, together with DAPT length.

Perspective:

This study reports that durable and biodegradable polymer stents, along with BRS, show a similar rate of MACE irrespective of DAPT length. Fewer MIs are observed with EES/ZES with DAPT >12 m, while a higher rate of ST is reported for BRS when compared to EES/ZES, independent of DAPT duration. A prolonged DAPT in patients treated with EES/ZES appears to reduce the occurrence of MI during follow-up compared with all the other types of stents, but is associated with an increased risk of bleeding. Clinicians need to balance ischemic and bleeding risk when considering duration of DAPT therapy, using guidance from the 2016 American College of Cardiology/American Heart Association Guideline Focused Update on Duration of DAPT.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS

Keywords: Acute Coronary Syndrome, Drug-Eluting Stents, Hemorrhage, Ischemia, Myocardial Infarction, Myocardial Revascularization, Platelet Aggregation Inhibitors, Polymers, Sirolimus, Stents, Thrombosis


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